
Class 11AM 

Book ,3)4 



Copyright^?. 



903 



COPYRIGHT DEPOSm 



DISEASES OF THE EAR 



A TEXT-BOOK 

FOR PRACTITIONERS AND STUDENTS 

OF MEDICINE 



BY 

EDWARD BRADFORD DENCH, Ph. B., M. D. 

Professor of Diseases of the Ear in the University and Bellevue Hospital 

Medical College ; Aural Surgeon, New York Eye and Ear Infirmary ; 

Consulting Otologist to St. Luke's Hospital ; Consulting Otologist 

to the New York Orthopaedic Dispensary and Hospital ; 

Fellow of the American Otological Society ; of the 

New York Academy of Medicine ; of the New 

York Otological Society ; of the New York 

County Medical Society, etc. 



WITH FIFTEEN PLATES AND 
ONE HUNDRED AND FIFTY- EIGHT ILLUSTRATIONS IN THE TEXT 



THIRD EDITION, REVISED AND ENLARGED 



: :.: :. : . .•• ..• • ■ • 

• ••• • i i • . . >■>> 

• ••••• ■•••••*••• » ' 

► •»» * * * • * » * • » * » • 



NEW YORK AND LONDON 

D. APPLETON AND COMPANY 

1903 




■■■ 



• 



THE LIBRARY OF 
CONGRESS, 

Two Copies Receive 

JUL 13 1903 

r Copyngnt Entry 
CLAS9J «• XXc. No. 

i h X ^i> 

COPY B. t 



Y 



&.£> 



JX 



Copyright, 1894, 1903, 
By D. APPLETON AND COMPANY. 



Electrotyped and Printed 
at the Appleton Press, XL S. A. 



PREFACE TO THIRD EDITION. 



The extensive advances which have been made in otolog- 
ical surgery during the last few years have rendered a complete 
revision of a large portion of this work necessary. This applies 
particularly to those chapters* devoted to the operative treat- 
ment of chronic suppurative otitis media, and of the various 
intracranial complications of middle-ear suppuration. While 
all of these subjects were considered both in the first and second 
editions, with the results of the author's investigations reported 
in full to date of publication, the technique of the radical opera- 
tion for the relief of chronic middle-ear suppuration, and those 
operations for the relief of sinus thrombosis and of brain ab- 
scess, were not considered in extenso. In the present edition 
of the work this fault has been remedied, and the technique of 
all of these major otological operations has been fully elabo- 
rated. In the detailed descriptions of each of these operative 
procedures, the author has laid particular stress upon those 
methods which, in his own experience, have proved most valu- 
able. Careful attention has, however, been paid to the work of 
other surgeons, and an attempt has been made to give a thor- 
oughly unbiased opinion as to the value of the different opera- 
tive methods in vogue at the present day. 

A number of new plates has been added to the book; all of 
the plates of bony specimens have been made from photographs 
taken by Dr. George S. Dixon, assistant pathologist at the New 
York Eye and Ear Infirmary, from specimens in possession of 
the author. The author desires here to express his thanks to 
Dr. Dixon for the careful manner in which he has conducted 
the work. 

The photographs of instruments have been prepared by my 
associate, Dr. Wm. P. Brandegee, and Dr. Dixon, and I desire 
to express my thanks to both of these gentlemen for the very 
efficient work which they have done. 

(iii) 



iv PREFACE TO THIRD EDITION. 

The two colored plates, showing the anatomy of the internal 
jugular vein and the technique of exploratory craniotomy, were 
prepared from actual dissections by the author, by Dr. H. J. 
Prentiss, to whom the thanks of the author are due. 

I also wish to express my thanks to Dr. Aimee Raymond 
Schroeder for valuable help in revising the work, and for the 
preparation of an elaborate index. 



PREFACE TO FIRST EDITION. 



In the preparation of the present work it has been my aim 
to adapt it to the needs both of the general practitioner and 
the special surgeon. For this reason minute pathology has 
not been considered extensively. 

In detailing the various manipulative procedures, I have 
preferred to err on the side of prolixity, for the benefit of 
those not familiar with the subject. It has also been my 
purpose to keep constantly before the reader, the fact that 
many diseases of the ear should not be considered by them- 
selves, for the reason that they are often local manifestations 
of systemic condition. 

Many works upon otology have failed to emphasize the 
importance of a thorough functional examination ; and none 
have placed the results of recent investigations at the disposal 
of the reader in such a manner as to enable him to use them 
in diagnosis. In consequence, I have written at length upon 
this subject. 

In advocating operative procedures upon the middle ear 
and in devoting much space to the subject of middle-ear 
operations, I am aware that I shall not have the support of 
many distinguished colleagues. As a careful reading of the 
chapter will show, I have written from personal experience : 
and if my results differ from those of other operators, I sug- 
gest that the selection of cases suitable for operation, accord- 
ing to the principles detailed in previous chapters, may 
account for the favorable outcome of the operations. 

In illustrating the gross pathological lesions of the con- 
ducting mechanism and the various manipulative measures 
instituted for their relief, I have adopted the plan of showing 
the auricle, meatus, and middle ear in the same drawing. The 
drawings are of natural size, and the technique of the various 
procedures seems to be made more clear in this manner, than 
by any other method. 

(v) 



vi PREFACE TO FIRST EDITION. 

In the colored plates of the membrana tympani, the adja- 
cent portion of the meatus is also shown, thus reproducing as 
completely as possible the picture seen upon speculum exami- 
nation, and rendering the relative position of the parts more 
intelligible. In this connection I desire to express my indebt- 
edness to Dr. W. A. Holden for the careful manner in which 
he prepared these plates from clinical cases. Without his aid, 
these illustrations would have been impossible. 

The absence of extensive bibliographical citations may 
seem a defect, but in a work intended as a clinical guide, a 
complete bibliography would be impossible, and unless com- 
plete it would be useless. No attempt has been made, there- 
fore, to collate the entire literature of any subject, and the 
citations have been limited to those necessary to give indi- 
vidual investigators the proper credit for their researches. 

It gives me pleasure to thank the W. F. Ford Surgical 
Instrument Company for the care which they have bestowed 
upon the illustrations of various instruments and appliances 
which appear in this volume. 

17 West 46TH Street, New York City, 
October 10, 18Q4. 



CONTENTS 



SECTION I. 
THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

CHAPTER I. 

PAGES 

The Anatomy of the Ear 3-47 

The auricle — The external meatus — The bony meatus — The tym- 
panic cavity — The ossicles — The intratympanic ligaments — The 
membrana tympani — The epithelial investment of the conducting 
apparatus — Intratympanic folds — The muscles — The arteries — The 
veins — The lymphatics — The nerves — The bony labyrinth — The 
membranous labyrinth — The saccule and utricle — The membranous 
cochlea — The vascular supply of the labyrinth — The auditory nerve. 

CHAPTER II. 
The Physiology of the Ear 48-72 

Sound — Function of the membrana tympani — Function of the ossi- 
cles — Function of the muscles — Function of the cochlea and semi- 
circular canals — Effect of tympanic changes upon the labyrinth — 
Effect of stimuli upon the auditory nerve — Reflex phenomena — 
Secondary phenomena — Hyperesthesia and paresthesia. 

CHAPTER III. 
Physical Examination 73-141 

Preliminary observations — Source of illumination — The Reflecting 
Mirror — Specula — Technique of Examination — Appearance of the 
meatus and membrana tympani — Obstacles to examination — Tym- 
panic topography — Politzerization — Catheterization — Auscultatory 
sounds — Obstacles to catheterization — Dangers of catheterization — 
The examination of the nose and throat — The history. 

CHAPTER IV. 
Functional Examination 142-170 

Quantitative tests — Qualitative tests — Bone conduction — Differential 
diagnosis — Precautionary measures — Irregular phenomena — Special 
tests — Galvanic reaction of the auditory nerve. 

(vii) 



viii CONTENTS. 

SECTION IT. 
DISEASES OF THE CONDUCTING APPARATUS. 

/. DISEASES OF THE AURICLE. 
CHAPTER V. 

PAGES 

Congenital Malformations of the Auricle . . . 173-182 

Deformities of particular parts of the auricle — Deformity or malpo- 
sition of the entire auricle — Auricular appendages — Polyotia. 

CHAPTER VI. 
Wounds and Injuries of the Auricle 183-186 

Contused, lacerated and incised wounds — The effect of intense cold 
— Burns — Injuries due to the action of chemical substances. 

CHAPTER VII. 
Cutaneous Diseases of the Auricle 187-199 

Intertrigo— Eczema — Pemphigus — Herpes — Syphilis — Lupus. 

CHAPTER VIII. 
Inflammatory Affections of the Auricle .... 200-205 

Perichondritis — Erysipelas — Abscess — Othsematoma — Thickening 
of the lobule — Ossification — Gangrene. 

CHAPTER IX. 

Benign Tumors of the Auricle 206-212 

Fibroma — Lipoma — Atheroma — Angioma — Cystoma — Papilloma. 

CHAPTER X. 
Malignant Tumors of the Auricle and of the Meatus. 213-216 

Epithelioma — Sarcoma. 

//. DISEASES OF THE EXTERXAL AUDITORY MEATUS. 

CHAPTER XI. 
Circumscribed External Otitis 217-237 

Acute Circumscribed External Otitis or Furuncle. vEtiol- 
ogy — Pathology — Symptomatology — Diagnosis — Prognosis — Treat- 
ment — Bloodletting — Cold — Instillations — Heat — Incision — Inter- 
nal medication. Chronic Circumscribed External Otitis. 
Significance in diagnosis of mastoid inflammation. 

CHAPTER XII. 

Diffuse External Otitis 238-266 

Chronic Diffuse External Otitis. ^Etiology — Pathology — 
Superficial — Cellular — Desquamative — Parasitic — Consecutive — 



CONTENTS. IX 

PAGES 

Symptomatology — Diagnosis — Prognosis — Treatment of the various 
varieties of the disease. Acute Diffuse External Otitis. 
^Etiology — Dependence upon the chronic form — Pathology — Symp- 
tomatology — Diagnosis — Involvement of middle ear — Prognosis — 
Treatment — Local depletion— Irrigation — Cold — Incision. CROUP- 
OUS and Diphtheritic External Otitis. Hemorrhagic 
External Otitis. 

CHAPTER XIII, 
Impacted Cerumen 267-278 

^Etiology — Pathology — Symptomatology — Direct and reflex phe- 
nomena — Diagnosis — Prognosis — Treatment — Use of the syringe — 
Use of the curette. 

CHAPTER XIV. 

Foreign Bodies in the Canal 279-284 

Etiology — Pathology — Symptomatology — Diagnosis — Prognosis — 
Treatment — Removal through the natural passage — Removal by 
external incision. 

CHAPTER XV. 
Exostosis of the External Auditory Meatus . . . 285-290 

^Etiology — Pathology — Symptomatology — Diagnosis — Prognosis — 
Treatment. 

CHAPTER XVI. 
Wounds and Injuries of the Membrana Tympani . . 291-296 

^Etiology — Pathology — Symptomatology — Diagnosis — Prognosis — 
Treatment. 



///. DISEASES OF THE MIDDLE EAR. 

CHAPTER XVII. 
Tubal Congestion, or Tubal Catarrh 304-316 

^Etiology — Pathology — Symptomatology — Diagnosis — Physical ex- 
amination — Functional examination — Prognosis — Treatment — In- 
flation — Dilatation — Medicated vapors — Prophylaxis. 

CHAPTER XVIII. 
Tubo-tympanic Congestion. — Tubo-tympanic Catarrh . 317-326 

.Etiology — Pathology — Symptomatology — Diagnosis — Physical ex- 
amination — Functional examination — Prognosis — Treatment — In- 
flation — Incision — Internal medication. 

CHAPTER XIX. 
Acute Catarrhal Otitis Media 327-340 

^Etiology — Pathology — Superficial structures alone affected — Symp- 
toms in adults — Symptoms in children — Inspection of discharge — 
Bacteriological examination of discharge — Diagnosis — Physical ex- 
amination — Functional examination — Prognosis — Treatment — De- 
pletion — Dry heat — Instillations — Incision — Irrigation — Topical ap- 
plications. 



CONTEXTS. 



CHAPTER XX. 

PAGES 

Acute Purulent Otitis Media 341-356 

.Etiology — Pathology — Bacteriological infection — Involvement of 
the connective tissue in the vault of the tympanum — Secondary in- 
volvement of the lower portion of the cavity — Extension to bony 
structures — Symptomatology — Evidences of mastoid involvement- 
Evidences of extension to the cranial cavity — Diagnosis— Phvsical 
examination — Bulging of membrana flaccida — Functional examina- 
tion — Prognosis — Subsequent functional condition — Chronic puru- 
lent otitis — Mastoid and intracranial involvement — Fatal cases — 
Treatment — Depletion — Early incision — Irrigation — Abortive treat- 
ment when mastoid symptoms appear — Ice coil and local blood- 
letting — Second incision unnecessary — Treatment of persistent dis- 
charge — Drainage. 

CHAPTER XXI. 
Chronic Catarrhal Otitis Media 357-396 

General considerations concerning pathological characteristics sep- 
arating the cases into two classes. Chronic Hypertrophic Oti- 
tis Media. -Etiology — Influence of repeated attacks of congestion 
— Unresolved acute otitis — Affections of the upper air passages — 
Sex — General condition — Heredity — Pathology — Tympanic changes 
— Changes in the drum membrane — In the Eustachian tube — In the 
tympanic ligaments — In the labyrinth— Symptomatology — Bilateral 
involvement — Intermittent character of the subjective noises and 
impairment of hearing — Vertigo — Reflex pain referred to the region 
of lingual tonsil —Diagnosis — Physical examination — Altered posi- 
tion and density of membrana tympani — Changes in the apparent 
breadth of malleus handle from rotation — Effusion — Functional ex- 
amination — Impairment for voice greater relatively than for sharp 
sounds — Changes in the limits of audition — Condition of organ sec- 
ondarily involved — Prognosis — Duration of affection— Condition of 
upper air passages — Degree of bilateral involvement — Age — Sec- 
ondary sclerotic changes — Treatment — Treatment of the upper air 
passages — Surgical measures and topical applications — Of the Eu- 
stachian tube — Inflation — Irrigation — Dilatation — Electrolytic 
method — Topical applications — Of the middle ear — Simple inflation 
— Medicated vaoors — Absorption or evacuation of effusion — Lavage 
of tympanum — Tenotomy of tensor tympani — Mechanical support 
in relaxation — Surgical procedures. Chronic Hyperplastic Oti- 
tis Media, -Etiology — Secondary to acute inflammations of tym- 
panum or to hypertrophic inflammation — Idiopathic disease result- 
ing from systemic causes — Occurrence in one ear as the result of 
changes in the opposite organ — Pathology — Sclerotic changes in the 
tympanic connective tissue — Deposit of new connective tissue — 
Changes in the membrana tympani — Deposits about oval and round 
windows — Tension anomalies causing rotation of malleus upon its 
long axis — Changes in the tympanic vault — Labyrinthine involvement 
— Condition of the Eustachian tube — Otosclerosis — Symptomatol- 
ogy — Insidious development — Subjective noises without impairment 
of hearing — Local and reflex pain — '' Auditor}' fatigue " — Neuras- 
thenic manifestations — Diagnosis — Physical examination — Normal 
appearance of drum membrane — Atrophy of membrane — Malposi- 
tion of ossicles — Appearance of membrana flaccida in cases second- 
ary to a hypertrophic process — Functional examination — Variation 
in lower tone limit — Bone conduction — Lateralization of tuning fork 
— Determination of relative amount of tympanic and secondary 
labyrinthine involvement in " mixed " cases by means of tuning 
forks — Changes in upper tone limit and its significance — Otosclerosis 
— Prognosis — Spontaneous cessation of the affection — Effect of men- 



CONTENTS. xi 



tal and physical exertion — Climatic influence — Age — Treatment — 
Of tympanum and tube — Passive motion — Massage — Pneumo-mas- 
sage contraindicated — Vibratory massage — Surgical measures — Of 
labyrinth — Internal medication — Effect of treatment of middle ear 
upon the labyrinth — Hygienic measures. 



CHAPTER XXII. 
Chronic Purulent Otitis Media 397-425 

^Etiology — Development from an acute catarrhal or acute purulent 
inflammation — Tuberculosis — Syphilis — Pathology — Necrosis of 
connective tissue and osseous structures — Caries of incus — Cause of 
its frequent occurrence — Labyrinthine involvement — Cerebellar ab- 
scess — Changes in the mastoid — Cholesteatoma — Symptomatology — 
Discharge — Variations in the amount of discharge — Occurrence of 
aspergillus— Facial paralysis — Presence of granulation tissue — Sec- 
ondary labyrinthine involvement — Diagnosis — Physical examination 
— Classification of conditions usually found upon inspection and 
their individual significance — Caries — Use of probe — Significance of 
granulation tissue — Displacement of the ossicles — Auscultatory signs 
— Functional examination — Variation in tone limits — Effect on 
upper tone limit — Bone conduction — Electrical reaction — Evidences 
of mastoid involvement — Prognosis — Probable effect upon audition 
— Cessation of discharge — Danger to life — Treatment — Use of sy- 
ringe — Other methods of cleansing — Treatment of the upper air 
passages — Instillations — Powders — Removal of exuberant granula- 
tion tissue — Irrigation of vault of tympanum — Operative procedures 
— Statistics of operations — Treatment after operation — Internal 
medication. 

CHAPTER XXIII. 

Otitis Media Purulenta Residua . . . . . 426-441 

Acute Type. ^Etiology — Identical with that of acute inflamma- 
tion of the normal tympanum — Pathology — Hyperemia of exposed 
lining of tympanum— Serous effusion — Becomes purulent by infec- 
tion through canal — Encysted effusion — Bony necrosis with devel- 
opment of chronic discharge — Symptomatology — Interference with 
function — Discharge — Secondary external otitis — Facial paralysis — 
Diagnosis — Physical examination — Serous discharge — Exfoliation of 
superficial epithelium — Thickening of remnant of drum membrane 
— Signs of mastoid involvement — Prognosis — Mild cases — Severe 
cases with retention of pus — Treatment — Mild cases — Asepsis — 
Topical applications — Treatment of upper air passages — Removal 
of dead bone if present to prevent recurrent attacks — Severe cases — 
Incision of membrana flaccida with cupping — Irrigation — Cold to 
mastoid. Chronic Type. Condition one of increased tension — 
Secondary effects on labyrinth — Pathology — Classification of condi- 
tions found in these cases — Symptomatology — Interference with 
function — Presence of inspissated secretion — Cholesteatoma — Pain 
in mastoid due to sclerotic changes — Diagnosis — Necessity of com- 
bining physical conditions with data obtained by functional exami- 
nation — Functional examination — Evidences of increased tension in 
conducting mechanism — Labyrinthine involvement — Determination 
of the degree to which perceptive and conducting mechanism 
is affected — Prognosis — Spontaneous improvement — Age — Influ- 
ence of labyrinthine involvement upon the prognosis — Recent and 
chronic cases —Treatment — General measures — Attention to upper 
air passages and Eustachian tube — Prophylaxis against otomy- 
cosis — Surgical treatment— Effect of treatment upon function of 
opposite ear. 



xii CONTENTS. 

IV. DISEASES OF THE MASTOID PROCESS. 
CHAPTER XXIV. 

PAGES 

The Anatomy of the Mastoid Process 442-448 

Variations in presence and location of pneumatic spaces — Location 
of antrum — Relations between superficial landmarks and cranial 
contents — Topographical variations dependent upon age. 

CHAPTER XXV. 
Inflammation of the Mastoid Process 449-462 

/Etiology — Secondary to middle-ear inflammation — Idiopathic cases 
— Pathology — Sclerotic changes — Caries and necrosis — Purulent in- 
flammation — Avenues of exit of secretion — Intracranial complica- . 
tions and channels of infection — Possibility of infection through 
outer surface of squama — Cholesteatoma — Symptomatology — Pain 
— Temperature not characteristic — Cessation of discharge — Evi- 
dences of intracranial involvement — Evidences of extension of 
thrombus from sinus into internal jugular vein — Diagnosis — Local 
tenderness — Method of eliciting symptom — Involvement of meatus 
close to membrana tympani — Evidences of external rupture — Of 
rupture into digastric fossa — Prognosis — Importance of early recog- 
nition — Chronic cases — Influence of diathetic conditions — Gravity 
of operative measures — Treatment — Free drainage through canal- 
Cold to mastoid — Abortive treatment by ice coil — Statistics — Irriga- 
tion of canal — Objection to Wilde's incision — Early and radical oper- 
ation. 

CHAPTER XXVI. 

Intracranial Complications of Tympanic Inflammation . 463-478 

Otitic Meningitis. Manner in which inflammation extends to 
meninges — Serous meningitis — Symptomatology — Variations de- 
pendent upon location of lesion — Ocular symptoms — Symptoms of 
serous meningitis — Diagnosis — Temperature — Headache — Vomiting 
— Choked disk — Prognosis — Advisability of operative interference — 
Treatment — Cold applications — Internal medication — Surgical 
treatment. Sinus Thrombosis. Avenues of infection — Extension 
to internal jugular — Secondary deposits — Symptomatology — Rigors 
and sweating — Intermittent temperature — General sepsis — Evi- 
dences of secondary deposits — Diagnosis — Value of frequent ther- 
mometric observations — Meningitis — Extension of thrombus — In- 
volvement of lymphatics — Examination for choked disk — General 
condition of patient — Prognosis— Apparent recovery — Statistics of 
results of operative treatment — Extension to internal jugular — Sta- 
tistics — Latent cerebral deposits — Treatment — Operative treat- 
ment — Medication — Alimentation. Extradural Abscess. Na- 
ture of the process — Symptomatology — Localized headache — Tem- 
perature changes — Mental condition — Prognosis — Latent deposits — 
Spontaneous evacuation — Value of operative treatment — Treatment 
— Necessity of surgical interference. Cerebral Abscess. Origin — 
Site — Latent deposits — Symptomatology — Dependent upon location 
— Aphasia and agraphia — Constitutional symptoms — Asthenia — 
Sleeplessness — Temperature — Diagnosis — General asthenic symp- 
toms — Sleeplessness — Low temperature — Difficulties in Diagnosis 
due to complicating lesions — Prognosis — Natural progress when not 
interfered with — Proper time for surgical interference — Results of 
operative treatment — Treatment — Evacuation by operation. Cere- 
bellar Abscess. Frequency — Pathological changes — Symptoma- 
tology — Vomiting — Dizziness and unsteadiness in gait — Dullness 
and apathy — Headache — Temperature— Diagnosis — Difficult be- 



CONTENTS. xiii 



cause of absence of pathognomonic symptoms — Choked disk maybe 
present — Symptoms may be those of* serous meningitis — Prognosis 
— Chances of recovery if recognized in time — Treatment — Evacua- 
tion by operation. 

SECTION III. 
SURGERY OF THE CONDUCTING APPARATUS. 

CHAPTER XXVII. 
Middle-ear Operations 481-531 

Preliminary Preparations. Instruments — Form — Construction 
— Sterilization — Field of operation — Necessity of asepsis — Method 
of securing an aseptic condition of the parts — Anaesthesia — Limita- 
tions of local anaesthesia — Conditions demanding general anaesthe- 
sia — Position of the patient — Advantages of elevation of head and 
shoulders. Classification of Operations. I. Operations upon 
the Membrana Tympani — Myringotomy for evacuation of fluid — 
For depletion — For exploration — Partial myringectomy — Multiple 
incisions — Plicotomy. II. Operations involving Section of Intra- 
tympanic Tissues — Tenotomy of the tensor tympani — Methods of 
operating — Division of the anterior ligament of the malleus — Divi- 
sion of adhesions in suppurative and nonsuppurative cases. III. 
Operations involving the Ossicular Chain — Excision of a portion of 
the manubrium — Disarticulation and mobilization of the stapes — 
Plastic operations — Removal of the ossicles — Technique when the 
membrana tympani is intact — Treatment after operation — Reaction 
following operation — Reproduction of the membrana tympani — 
Technique when membrane is partially destroyed — Haemorrhage 
during operation — Difficulty of securing the remnant of the incus — 
Curetting of tympanum after removal of ossicles — Subsequent treat- 
ment — Details of technique of disarticulation at the incudo-stape- 
dial joint and removal of the incus — Frequency of caries of incus — 
Control of haemorrhage — Possible accidents — Stacke's operation — 
Author's operation — Statistics — Stapedectomy — With intact drum 
membrane — With drum membrane partially destroyed — Statistics 
of author's operations showing the effect upcn the function of audi- 
tion in cases operated upon. 

CPIAPTER XXVIII. 
The Mastoid Operation 532-545 

Instruments— Preparation of field of operation — Incision — Separa- 
tion of sterno-mastoid muscle — Removal of cortex — Removal of 
softened bone — Accidents during operation — Opening of lateral 
sinus — Treatment — Laceration of dura — Treatment — Dressing — 
After-treatment — Technique of operation in young children — Tech- 
nique in mastoid sclerosis — Destruction of osseous tissue — Traut- 
mann's operation for closure of opening — Mosetig-Moorhof s method 
— Paraffin treatment reported by Frey — Technique of injection. 

CHAPTER XXIX. 

Radical Operation for Chronic Otorrhcea — Stacke- 

Schwartze Operation 546-563 

Necessity for free drainage — Combination of the methods of Kiister, 
Bergmann, and Stacke to form Stacke-Schwartze operation — Tech- 
nique — Situation of incision varies with operators — Structures to be 
avoided in operating— Lining of cavity with flaps — Panse's modifi- 
cation — Koerner's modification — Tansen's modification — Ballance's 



xiv CONTENTS. 



method — Author's method — Tiersch grafting — Irrigation of wound 
at first dressing — Dressing—Results of operation — Author's statistics 
— Secondary operation — Accidents during operation — Injury of facial 
nerve — Exposure of dura — Exposure of lateral sinus — Treatment 
after accidents — Perichondritis of auricle. 



SECTION IV. 

THE SURGICAL TREATMENT OF INTRACRANIAL COMPLICA- 
TIONS OF AURAL SUPPURATION. 

Introductory Remarks . 569-570 

Necessity for operation — Hesitation justified in extensive meningitis 
— Wisdom of making an ample opening — Displacement of a semi- 
circular flap. 

CHAPTER XXX. 

Sinus Thrombosis 571-578 

Perforation of skull — Necessity for asepsis — Care in use of rongeur 
forceps — Signs of normal sinus — Exploratory puncture valueless — 
Site for incision — Signs of clot- — Relative importance of haemorrhage 
from above and from below — Breaking down of clot — Symptoms of 
extension of thrombus into internal jugular — Excision of infected 
vein — Technique of operation — Not advisable to wash out clot by 
injection of fluid into proximal extremity of vein — Dressing — Statis- 
tics of results. 

CHAPTER XXXI. 

Otitic Meningitis 579—585 

Exploratory craniotomy — Relief of intracranial tension — Incision 
for evacuation of fluid in lateral ventricles — Technique — Lumbar 
puncture — Method of performing puncture — Necessity for asepsis — 
Value as a diagnostic measure — Normal pressure of spinal fluid — 
Increase of pressure in meningitis — Lumbar puncture of no value as 
a therapeutic measure — Epidural abscess — Usual location — Opera- 
tion — Irrigation of abscess cavity. 

CHAPTER XXXII. 
Cerebral and Cerebellar Abscess 586-594 

Symptoms of cerebral abscess obscure — Location of abscess — 
Puncture — Operation and evacuation of pus — Danger of inserting 
instrument into cerebral substance — Disadvantage of irrigation at 
time of primary operation — Packing of abscess cavity with gauze — 
Whiting's encephaloscope — After-treatment of wound — Method of 
dressing varies with different authorities — Drainage tube advisable — 
Precautions to avoid retention of pus, and the protrusion of brain 
substance — Evacuation of lateral ventricle if entered during explora- 
tory incision — Cerebellar abscess — Exploratory incision — Evacua- 
tion of pus — Cleansing of cavity with gauze or cotton mops — Dress- 
ing of wound. 

SECTION V. 

DISEASES OF THE PERCEPTIVE MECHANISM. 

Introductory Remarks . 597-600 

Character of auditor}' impairment — Comparative value of physical 
and functional examination — Importance of complete history — Lo- 
cation of the pathological process. 



CONTENTS. xv 



CHAPTER XXXIII. 

PAGES 

Anemia of the Labyrinth 601-603 

^Etiology — Profuse haemorrhage — Constitutional conditions — Symp- 
tomatology — Functional impairment — Subjective noises — Disturb- 
ances of static function — Diagnosis — Physical examination — Func- 
tional examination — Tone limits often preserved or upper tone limit 
may be lowered — Deficient bone conduction — General anaemia — 
Prognosis — Dependent upon cause — Treatment — Stimulants — Ton- 
ics — Drugs to be avoided. 

CHAPTER XXXIV. 

Hyperemia of the Labyrinth 604-607 

.Etiology — General condition — Occupation — Concussion — Acute or 
chronic venous engorgement — Pathology — Dilatation of veins — Ex- 
travasation — Serous transudation — Symptomatology — Variations in 
degree and persistence of the manifestations — Diagnosis — Absence 
of definite physical signs — Functional examination — Preservation of 
lower tone limit — Upper tone limit reduced — Impairment of bone 
conduction — Prognosis — Varies with duration and degree of process 
— Treatment — Acute cases — Depletion — Rest — Occlusion of" canal 
— Pilocarpine — Chronic cases — Counter-irritation — Pilocarpine and 
the method of its administration — General hygienic rules. 

CHAPTER XXXV. 

Labyrinthine Hemorrhage . . .- . . . . 608-610 

^Etiology — Concussion — Direct traumatism — Blood conditions — 
Changes in the walls of the blood vessels — Diatheses — Pathology — 
Extravasation — Subsequent changes — Symptomatology — Prodro- 
mata — Sudden access of symptoms — Symptoms usually severe — 
Gradual abatement of manifestations — Recurrence — Diagnosis — 
Value of clinical history — Functional examination — Absence of 
bone conduction — Absolute deafness or great auditory impairment 
— Upper tone limit reduced — Occasional disturbances of lower tone 
limit — Prognosis — Varies with the severity of haemorrhage — Static 
function usually restored — Treatment — Acute stage — Depletion — 
Rest — Revulsives — Chronic stage — Reduction of labyrinthine pres- 
sure — Prophylaxis. 

CHAPTER XXXVI. 

Labyrinthine Embolism and Thrombosis .... 611-612 

^Etiology — Metastasis — Inflammation of contiguous structures — Pa- 
thology — Results in local anaemia — Local necrosis — Inflammation — 
Symptomatology — Function of organ usually not much disturbed — 
Spontaneous improvement — Prognosis — Condition not progressive — 
Treatment — Removal of cause — Reduction of labyrinthine pressure 
— Relief of subjective symptoms — Stimulation of impoverished nerve 
tissue. 

CHAPTER XXXVII. 
Specific Inflammation of the Labyrinth .... 613-616 

.Etiology — Hereditary or acquired syphilis — Pathology — Chronic 
inflammatory changes — Hypertrophy — Changes in walls of vessels 
— Necrosis — Symptomatology — Sudden access in acquired form — In- 
vasion less sudden in hereditary cases — Diagnosis — Physical exami- 
nation — Recognition of concomitant tympanic disease — Functional 
examination — Deficient bone conduction — Lowering of upper tone 
limit — Differential diagnosis in "mixed" form — Prognosis — In- 



xvi CONTENTS. 

PAGES 

fluence of heredity — Age of local process — Spontaneous quiescence 
— Treatment — Antisyphilitic medication — Pilocarpine — Iodide of 
potassium — Strychnine in advanced cases — Tonic treatment in he- 
reditary cases. 

CHAPTER XXXVIII. 

Inflammation of the Labyrinth secondary to Chronic 
Suppurative and Nonsuppurative Inflammation of 
the Tympanum . . 617-628 

Pathology — Inflammatory changes — Atrophic changes — Extension 
of inflammation from tympanum — Condition of oval and round win- 
dow — Results of suppuration — Functional disturbances — Symptom- 
atology — Subjective noises — Significance of disappearance of tin- 
nitus — Vertigo — Sympathetic involvement of opposite ear — Diag- 
nosis — Physical examination — Absence of physical signs in certain 
cases — Value of inspection in residual purulent cases — Functional 
examination — Evidences of obstruction to sound conduction — Ne- 
cessity of repeated examinations — Determination of relative impor- 
tance of tympanic and labyrinthine lesion — Electrical tests — Im- 
portance of examination upon both sides to determine secondary 
involvement of apparently healthy organ — Prognosis — Residual 
purulent cases usually progress but slowly or not at all — Dangers of 
sympathetic involvement — Treatment — Relief of cause in middle 
ear — Preservation of organ involved secondarily — Special measures 
directed toward labyrinth — Pilocarpine — Strychnine — Specific treat- 
ment — Persistent stimulation by sonorous vibrations — Relief of sub- 
jective noises — Treatment of the upper air passages — Danger of 
treating middle ear in advanced cases. 

CHAPTER XXXIX. 

Acute Inflammation of the Labyrinth secondary to 

Acute Purulent Otitis Media 629-633, 

^Etiology — Ordinary causes of acute purulent otitis media — Viru- 
lence of process — Pathology — Tissue necrosis — Avenues of infection 
— Infection of cranial contents — Obliteration of labyrinth from de- 
posit of new tissue — Symptomatology — Not characteristic in young 
subjects — Evidences of labyrinthine infection in adults — Importance 
of facial paralysis as a symptom — Disturbance of static function — 
Retrogression of symptoms — Haemorrhage — Permanent impairment 
of audition — Diagnosis — Physical examination — Not characteristic 
of labyrinthine involvement — Evidences of caries of internal tym- 
panic wall — Functional examination in children unsatisfactory — In 
adults — Upper tone limit much lowered— Bone conduction absent 
or greatly reduced — Vertigo — Prognosis — Unfavorable for complete 
restoration of function — Often fatal in children — In adults not as 
great a menace to life — Danger of absolute deafness less common in 
adults — Danger of causing deaf-mutism in children — Treatment — 
Prophylaxis against infection by asepsis from the first — Relief of tin- 
nitus — Procedures to combat extension to meninges — Cold locally — 
— Purgation — Value of pilocarpine after acute stage has been 
passed. 

CHAPTER XL. 

Involvement of the Perceptive Mechanism in the Acute 

Infectious Diseases 634-640 

Introductory remarks— Direct infection of labyrinth — Concomitant 
middle-ear inflammation — Pathology — Inflammatory changes — In- 
crease of tension by effusion — Occlusion of vestibular and cochlear 
aqueducts — Symptomatology — Impairment of function — Tinnitus — 
Influence of age of patient upon manifestations — Resultant mutism 



CONTENTS. xvii 

PAGES 

in children — Diagnosis— Simple if middle ear is normal — Determi- 
nation of labyrinthine lesion if tympanum is also affected — Value of 
functional examination in differential diagnosis — " Tone gaps " — 
Prognosis — Not grave in recent cases — More amenable to treatment 
in children than in adults — Treatment — Reduction of labyrinthine 
pressure by pilocarpine — Strychnine in chronic cases — Value of per- 
sistent education of power of audition. Effect of Certain Par- 
ticular Diseases of this Class. Mumps. Metastatic infec- 
tion of labyrinth — Prognosis excellent in cases subjected to medica- 
tion at an early period. Typhus and Typhoid Fever. Probably 
causes changes in cortical centres — Usually disappear during conva- 
lescence. Epidemic Influenza ; Diphtheria. Probable involve- 
ment of nerve trunk — Impairment in audition for middle portion of 
musical scale — Tone limits unchanged — Galvanic hyperesthesia — 
Bone conduction not lost, but reduced — Treatment directed toward 
improving general condition — Value of strychnine after acute stage. 
Epidemic Cerebro-spinal Meningitis. Pathology — Extension 
to labyrinth through aqueducts — Inflammatory changes — Extravasa- 
tion — Deposit of new tissue — Secondary invasion of tympanum — 
Symptomatology — Vertigo — Severe tinnitus — Hyperacusis — Para- 
lytic symptoms — Diagnosis — Physical examination — Negative unless 
tympanum is secondarily involved — Functional examination — Pro- 
found impairment of audition — Upper tone limit greatly reduced as 
a rule — Exceptions — Effect of hyperesthesia on the perception of 
low notes — Bone conduction almost or entirely wanting — Prognosis 
— Complete deafness in severe cases — Significance of disappearance 
of tinnitus — Danger of mutism in children — Treatment — Prophy- 
laxis impossible — Local depletion and catharsis in early stages — 
Pilocarpine valuable after acute stage — Cases of long standing — 
Strychnine — Value of systematic exercise of auditory function by 
the use of conversation tube, etc. 

CHAPTER XLI. 

Involvement of the Perceptive Mechanism in Acute 

Meningitis 641-645 

Pathology — Labyrinthine lesion — Involvement of nerve trunk — 
Cortical lesions — Symptomatology — Variations due to location of 
lesion — In the labyrinth — Subjective noises — Vertigo — Impaired 
audition — Affecting nerve trunk — Interference with perception of 
middle notes of musical scale — Limits of audition normal — Signifi- 
cance of unilateral impairment — Cortical lesion — Bilateral impair- 
ment — Word deafness — Later symptoms — Diagnosis — Physical ex- 
amination — Negative frequently — Importance of rupture of mem- 
brane in traumatic cases — Functional examination — Characteristics 
of labyrinthine lesion — Of lesions of nerve trunk — Of cortical in- 
volvement — Value of electrical tests — Prognosis — Treatment — Acute 
stages — Pilocarpine in later stages — Iodide of potassium — Strych- 
nine — Exercise of auditory function. 

CHAPTER XLII. 

The Effect of Diseases of the General Nervous Sys- 
tem upon the Perceptive Mechanism .... 646-648 

Cortical Lesions. Bilateral involvement — Word deafness — Audi- 
tory hallucinations — Intermittent tinnitus. Tabes Dorsalis. De- 
generation of nerve trunk — Galvanic hyperesthesia — Perception of 
middle notes impaired — Torpidity of nerve in later stages. Lesions 
of Vestibular Nerve and of Cerebellum. Disturbance of 
equilibrium — Diagnosis — Dependent upon general rather than spe- 
cial symptoms — Treatment — Value of bromides — Strychnine — Anti- 
syphilitic medication. 



xviii CONTENTS. 

SECTION VI. 
COMPLICATING AURAL AFFECTIONS. 

CHAPTER XLIII. 

PAGES 

Aural Affections complicating the Acute Infectious 

Diseases 651-653 

Affection of perceptive apparatus — Involvement of conducting mech- 
anism — Character determined by degree of infection — Portions of 
tympanum involved — Extension to other regions. 

CHAPTER XLIV. 

Aural Affections dependent upon Chronic Visceral 

Conditions 654-661 

Symptoms due chiefly to circulatory changes. Nephritis. Effect 
due to venous obstruction — Arterial sclerosis and impoverished 
quality of blood — Tympanic effusion — Extravasations — Labyrin- 
thine haemorrhage — Haemorrhage into nerve sheath. Metastasis. 
Embolism of labyrinthine vessels from remote suppurative process 
— Infection of middle ear. Tuberculosis. Tympanic involve- 
ment — Absence of pain — Multiple perforation — Constitutional 
treatment — Effect of tympanic process upon general condition. 
Leucaemia. Extravasation into labyrinth — Deposit of new tissue — 
Sudden appearance of symptoms — Diagnostic data. Diabetes. 
Frequency of inflammation in external meatus — As predisposing 
cause of middle-ear suppuration — Extravasations in labyrinth, nerve 
trunk, or centres. Gout and Rheumatism. Cutaneous manifes- 
tations in canal — Arthritic inflammation in middle ear — Changes in 
the blood vessels and the results. Medicinal Substances. Qui- 
nine — Effect on middle ear and labyrinth — Salicin and salicylic 
acid — Conditions contraindicating their administration — Tobacco — 
Effect upon higher centres. 

CHAPTER XLV. 

Disturbances of Audition dependent upon Functional 

Nervous Disorders . . 662-667 

Unimportant physical changes as a cause of manifestations in a par- 
ticular region — Perversion or impairment of function with no evi- 
dent lesion. Neurasthenia. " Auditory strain " — Psychological 
effect — Character of impairment of hearing — General sensory pares- 
thesia — Diagnosis — Physical examination often negative— Func- 
tional examination — Perception of high and low notes — Reduction 
of bone conduction — Variable results obtained by successive tests — 
Recognition of general neurotic condition — Hyperacusis — Auditory 
fatigue — Prognosis — Influence of organic changes in ear — Influence 
of general neurosis — Treatment — Strychnine— Bromides — Rest — 
Change of habit of life. Hysteria. Degree of impairment — Sud- 
den appearance — Subsequent course — Associated hysterical paral- 
yses — Transference — Absence of subjective noises — Diagnosis — 
Sudden onset — Absence of physical changes — Cutaneous anaesthesia 
— Functional examination — Contraction of range of audition — Up- 
per tone limit most affected — Alternate variations in upper limit — 
Contraction of field of vision — Prognosis — Treatment — Attention to 
general neurosis — Hypnotic treatment. 



CONTENTS. xix 



CHAPTER XLVI. 

PAGES 

Reflex Aural Disturbances . . . . . . . 668-673 

Vaso-motor changes — Trophic disturbances. External Meatus. 
Reflex inflammation — Cutaneous hyperesthesia — Haemorrhage. 
Middle-ear. Reflex otitis media — Otalgia — Angioneurotic oedema 
of mastoid. Perceptive Mechanism. Paresthesia — Influence of 
visceral disorders — Interference with static function — Irregularity 
and transitory character of symptoms — Absence of local cause — 
Presence of remote lesion — Effect of one ear upon opposite organ — 
Physiological interdependence — Pathological correlation — Value of 
electrical hyperesthesia in diagnosis — Prognosis — Duration of reflex 
symptoms — Nature of exciting cause — Treatment — Early. adminis- 
tration of bromides — Removal of exciting cause — Antispasmodics — 
Opium contraindicated — Tonic treatment. 

CHAPTER XLVII. 

Deaf-mutism 674-679 

Definition — Varieties — ^Etiology. Congenital Form. Heredity 
— Consanguinity — Nationality — Social condition — Defective mental 
development — Specific disease — Causes operative during intrauter- 
ine life. Acquired Form. Traumatism — Infectious diseases — 
Intracranial disease — Middle-ear inflammation — Adenoid vegeta- 
tions and the resultant tympanic condition — Cause of mutism in 
acquired form — Pathology — Congenital malformation of conducting 
or perceptive mechanism— Obstructive lesions of canal or tym- 
panum from a pathological process — Pathological conditions in the 
perceptive mechanism — Secondary atrophic changes — Symptoma- 
tology — Mutism in young children — In older children auditory im- 
pairment first noticed — Diagnosis — Difficulties in very young chil- 
dren — Importance of complete history — Importance of thorough 
functional examination with a series of musical tones — Prognosis — 
Congenital cases — Acquired cases — Possible errors — Treatment — 
Elimination of possible causes present — Removal of adenoid vege- 
tations — Internal medication — Necessity of early diagnosis — Early 
systematic instruction in cases not amenable to treatment. 

DISEASES OF THE NOSE AND NASO-PHARYNX. 

Classification of pathological conditions — Manner in which various 
local lesions affect sense of hearing. 

CHAPTER XLVIII. 

Hypertrophic Rhinitis. — Deformities of the Nasal Sep- 
tum 680-685 

Hypertrophic Rhinitis. Nature of tissue changes — Resultant 
conditions — Symptoms referable to upper air passages — Aural symp- 
toms — Referable to middle ear — Influence upon labyrinth — Relief 
of labyrinthine symptoms from intranasal treatment — Speculum ex- 
amination — Evidences of hypertrophy — Changes following the use 
of cocaine — Effect of treatment — Technique of local application — 
Surgical treatment. Deformities of the Nasal Septum. Method 
of removal with saw — Preparation of instruments — Dressing — Use 
of galvano-cautery. 

CHAPTER XLIX. 

Atrophic Rhinitis 686-688 

Pathological changes in membrane — Conditions resulting from the 
atrophic process — Insignificance of aural symptoms — Relation be- 



xx CONTEXTS. 



tween aural and nasal conditions — Treatment — Irrigation — Precau- 
tions in using nasal douche — Results of intranasal treatment upon 
the aural symptoms — Sprays — Local stimulation. 

CHAPTER L. 

Adenoid Vegetations 689-692 

Importance of condition — Diathetic nature of affection — Symptoms 
referable to upper air tract — Aural symptoms — Otalgia — Discharge 
— Impairment of function — "Inattention" as a symptom — Condi- 
tion of oro-pharynx — Posterior rhinoscopy — Recognition by anterior 
rhinoscopy — Digital exploration — Technique of removal with for- 
ceps and curette — Possible sequelae to operation — Enlarged faucial 
tonsils — Effect upon audition — Methods of removal in children and 
adults. 

CHAPTER LI. 

Naso-pharvngeal Catarrh 693-694 

Atrophic nature of process — Symptoms referable to vault of phar- 
ynx — Changes in ear concomitant rather than resultant — Aggrava- 
tion of aural condition by changes in naso-pharynx — Effect upon 
audition of treatment of naso-pharynx — Topical applications in 
acute conditions — Topical applications in chronic conditions. 

CHAPTER LIE 
Artificial Aids to Hearing 695-696 

Ear trumpet — Modifications of — Cane — Fan — Lorgnette — Tele- 
phone instrument. 



LIST OF ILLUSTRATIONS. 



PLATES. 



FACING 
PAGE 



I —Anatomical Plate: (A) View of Tympanic Ring with 
Wall of Middle Ear and Ossicles ; (£) Semicircu- 
lar Canals and Facial Canal 

II. — Anatomical Plate: (A) Section through Middle Ear; 
(B) Section through Temporal Bone, showing Mas- 
toid, Facial Canal, and Internal Wall of Middle 
Ear 

The Arterial Supply of the Conducting Apparatus 

The Venous Supply of the Conducting Apparatus 

The Vascular Supply of the Cochlea 

The Auditory Nerve 

Bezold Continuous Tone Series 

Bezold Continuous Tone Series 

The Membrana Tympani (i-6) 

The Membrana Tympani (7-12) 

The Mastoid Operation . 

Instruments for Mastoid Operation 

Instruments for Radical Operation 

•Exploration of Middle Cranial Fossa. Lateral Si- 
nus and Cerebellum. Ligation of Internal Jugu- 
lar 

XV. — Dissection of Internal Jugular Vein, showing Free 
Venous Anastomosis as Contrasted with Plate 
XIV 



III. 

IV. 

V. 

VI, 

VII.- 

VIII, 

IX. 

> X. 

XI, 

XII, 

XIII, 

XIV. 



14 



15 

28 

30 
31 

45 
150 
150 
297 
297 
532 
534 
546 



57i 



575 



ILLUSTRATIONS IN THE TEXT. 

FIGURE 

1. The cartilaginous framework of the auricle 

2. The auricle ..... 

3. The cartilaginous meatus 

4. The incisures of Santorini 

5. The development of the temporal bone 

6. Temporal bone of infant 

7. The adult temporal bone 

8. The external meatus and membrana tympani of a child at birth 



4 

5 
6 

7 

S 

9 
10 



xxii LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

9. External meatus, membrana tympani, and middle ear from a child five 

years old .11 

10. Sagittal section through external auditory meatus, membrana tympani, 

and middle ear of an adult . . .11 

11. The internal tympanic wall . . . 12 

12. The internal tympanic wall and the vault of the tympanum, with ossi- 

cles in situ . . . -.---.- . . " . - . . .14 

13. The ossicles and the annulus tympanicus . . . . . . 15 

14. The malleus, incus, and stapes in various positions . . . .16 

15. The tympanum from above . . 18 

16. Section through mastoid, tympanum, and Eustachian tube . . .19 

17. Transverse section of Eustachian tube 20 

18. The pockets of the membrana tympani -. . . . . .24 

19. The malleo-incudal articulation covered by the superior malleo-incudal 

fold . . 24 

20. The nerves of the conducting mechanism and their anastomotic 

branches . . . . . 32 

21. The nerve distribution within the tympanum 33 

22. The bony labyrinth . . . . . . . . . -34 

23. The membranous labyrinth . . . - . . . . ...... -38 

24. Vertical section of the membranous cochlea 42 

25. Pen drawing from adult specimen, showing result of drawing auricle 

upward and backward . . . . . . . . -73 

26. Drawing from specimen at birth . . . . . . . -74 

27. Drawing from specimen from child aged five years . . . -74 

28. Author's portable illuminating apparatus ...... JJ 

29. Hand mirror •.-•-. . . -79 

30. Reflecting mirror adapted for hand or head 80 

31. Head mirror with nasal support . . . . . . .81 

32. Head mirror. . . . . . . . . . .81 

33. Electric lamp worn upon the forehead 82 

34. Politzer's hard-rubber aural speculum 84. 

35. Wilde's aural speculum 84. 

36. Gruber's aural speculum .85 

37. Toynbee's aural specula . . -85 

38. The ocular inspection of the membrana tympani . . . . .87 

39. The normal membrana tympani . . . . . . . . 91 

40. Middle-ear probe . . ... . 99 

41. Cotton holder . . . . . . . . . . . 100 

42. Siegle's pneumatic speculum 101 

43. Auscultation tube . . . . . - 103 

44. Politzer's air bag .104 

45. The Eustachian catheter 107 

46. Introduction of the Eustachian catheter (first step) . . . .111 

47. Introduction of the Eustachian catheter (second step) . . .111 

48. Introduction of the Eustachian catheter (the instrument in the mouth 

of the tube) . . 112 

49. Vertical section through nasal chambers and pharyngeal vault of adult. 119 



LIST OF ILLUSTRATIONS. 



xxm 



50. The same in a child of five years . 

51. Section through nasal passages and naso-pharyn 

52. Noyes's Eustachian catheter 

53. Pomeroy's faucial catheter .... 

54. Bosworth's nasal speculum . ... 

55. Bosworth's tongue depressor 

56. Folding tongue depressor .... 
Tiirck's tongue depressor .... 

Rhinoscopic mirror 

Politzer's acoumeter 

Urbantschitsch's electric acoumeter 

The author's tuning fork .... 

The author's modification of the Galton whistle 

Blake's tuning fork 

Hartmann's series of tuning forks 

Congenital asymmetry and deformity of auricle 



57 
58 

59 
60 
61 
62 

63 
64. 
6\a. 

65. Anomalous division of the antihelix 

66. Microtia ..... 

67. Auricular appendage . 

68. Fistula congenita auris 

Polyotia 

Aural ice bag .... 
Deformity following perichondritis 
Othematoma .... 
Soft fibroma filling the concha 

Fibroma of lobule 



69. 
70. 

71. 

72. 

73- 

73*- 

74. Atheroma . . . . 

75. Sebaceous tumor of the lobule 

76. Cystoma of auricle . . 
76a. Horny growth from lobule 

77. Otitis externa acuta circumscripta 

78. Otitis externa acuta of deep portion of meatus 

79. Bacon's scarificator 

80. Author's artificial leech .... 
Si. The Leiter coil 

82. Hard-rubber ear syringe .... 

83. Development of a fungus .... 

84. Microscopic characteristics of otomycosis . 

85. Otomycosis 

86. Aspergillus flavus 

87. Appearance in infancy due to escape of fluid fro 

Rivinian fissure ..... 
SS. Acute diffuse external otitis .... 

89. Crust on supero-posterior wall of canal covering 

bran a tympani ..... 

90. Method of removing cerumen with the curette 

91. Linear rupture of the membrana tympani 

92. Retraction of the membrana tympani . 



x in an infant 



tympanum thr 



perforation in 



ousfh 



PAGE 
I20 

121 
124 
125 

135 
137 
137 
137 
138 

143 
I46 
I48 
156 

157 
158 
172 

175 
176 
179 
179 
l8o 
185 
200 
202 
206 
206 
208 
208 
211 
212 
222 
223 
227 
228 
229 

234 
241 
242 

246 



249 

257 



276 
293 

JO? 



xxiv LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

93. Author's bougie catheter for the Eustachian tube . . . . 313 

94. Author's middle-ear vaporizer 315 

95. Moderate retraction of membrana tympani ; incudo-stapedial articu- 

lation visible. . .321 

96. Bulging of the posterior segment of the membrana tympani . . 321 

97. Method of incising the membrana tympani 325 

98. Moderate bulging of the entire membrana tympani .... 333 

99. Blake's middle-ear syringe 339 

100. Acute purulent otitis media ; bulging of membrana flaccida . . 346 

101. Acute purulent otitis media; fluid confined in the pockets of the 

membrane 347 

102. Chronic catarrhal otitis media; rotation of malleus upon its long 

axis 364 

103. Chronic catarrhal otitis media ; supernumerary posterior fold . . 365 

104. Chronic catarrhal otitis media ; moderately retracted membrane . 385 

105. Delstanche's masseur 389 

106. Chronic purulent otitis media ; extensive destruction of membrana 

vibrans 405 

107. Chronic purulent otitis media; exuberant granulations in tympanum. 405 

108. Chronic purulent otitis media ; margin of perforation partially ad- 

herent . 405 

109. Chronic purulent otitis media ; perforation in membrana flaccida . 406 
no. Chronic purulent otitis media ; displacement of ossicles . . . 406 
in. Chronic purulent otitis media ; small perforation in posterior quad- 
rant ............ 406 

112. Removal of an aural polyp with the snare 416 

113. Removal of an aural polyp with the sharp curette .... 417 

114. Irrigation of the tympanic vault . . 420 

115. Inspissated secretion covering a small perforation in the membrane . 434 

116. The pneumatic mastoid . 442 

117. The diploic mastoid 443 

118. Horizontal section through, mastoid, showing the position of the sig- 

moid groove. . 444 

119. Section through mastoid, showing the relative position of the lateral 

sinus and the antrum 444 

120. Section through mastoid, showing the sinus in an anomalous posi- 

tion 445 

121. Anomalous development of the temporal ridge 447 

122. The tympanic vault and mastoid antrum at birth .... 448 

123. Instruments for middle-ear operations 482 

124. Author's head and shoulder rest .485 

125. Lance-shaped myringotome 486 

126. Method of incising the membrana flaccida for depletion . . . 488 

127. Exploratory myringotomy 489 

128. Author's scissors for middle-ear operations 491 

129. Hartmann's tenotome . . 493 

130. Tenotomy of the tensor tympani 494 

131. Tenotomy of the tensor tympani . 494 



LIST OF ILLUSTRATIONS. 



XXV 



FIGURE 

132. Tenotomy of the tensor tympani 

133. Division of tympanic adhesions . 

134. Division of adhesions behind the stapes 

135. Disarticulation at the incudo-stapedial join 

136. Exposure of the incudo-stapedial join 

137. McKay's ear forceps . 

138. Incus hook in position 

139. Author's chisel forceps 

140. Incus partially destroyed by caries 

141. Trautmann's plastic operation for closure of opening behind the ear 

142. Same operation, showing manner of passing sutures . 

143. Trautmann's operation, showing deep sutures tied, and superficial 

wound closed with interrupted sutures .... 

144. Mosetig-Moorhofs operation for closure of retro-angular fistula 

145. Exposure of tympanic vault and its contents .... 

146. Appearance of bony cavity after the complete radical operation 

147. Complete Stacke-Schwartze operation ..... 

148. Stacke-Schwartze operation. Formation of flaps by Panse's method 

149. Stacke-Schwartze operation. Formation of flap by Korner's method 

150. Incision of concha to form conchal flap. Ballance's method 

151. Conchal flap sutured in position. Ballance's method 

152. Passow's method of lining the operation wound by a skin flap taken 

from the neck . 

153. Formation of flaps for lining the bony cavity after radical operation 

Method of Jansen and Forselles ...... 

154. Method of Schwartze and Kretschmann of lining bony cavity with 

skin flaps 

155. Ballance's instruments for skin grafting 

156. Lateral aspect of skull showing Reed's base line 

157. Whiting's encephaloscope ........ 

158. Section through middle turn of the cochlea in leucaemia, showin 

infiltration ........... 



PAGE 

495 
497 
499 
499 
503 
5o5 
507 
509 
523 
54i 
54i 

542 
543 
55o 
55i 
552 
553 
553 
554 
554 

555 
556 

556 

558 
566 
590 

658 



SECTION I. 

THE ANATOMY AND PHYSIOLOGY 
OF THE EAR. 



THE ANATOMY AND 
PHYSIOLOGY OF THE EAR. 



CHAPTER I. 

THE ANATOMY OF THE EAR. 

The auditory apparatus, through the agency of which 
certain forms of motion are interpreted as sound, may best 
be considered as consisting of two parts — a conducting mech- 
anism and a receptive mechanism. The conducting mech- 
anism collects the vibrations of the sounding body and trans- 
mits them to the receptive mechanism, through which this 
motion is recognized as sound. 

This division of the subject affords a much clearer view of 
the function of the various parts concerned in audition, in 
health and in disease, than that obtained by adhering strictly 
to the anatomical divisions of the external, middle and inter- 
nal ear. 

The conducting apparatus includes the external and mid- 
dle ear. The middle ear is simply the more delicate and 
complicated portion of the transmitting mechanism, and 
therefore is more carefully protected from injury, both bv its 
situation at a distance from the external surface of the body 
and by the presence of the membrana tympani. It is probable 
that the function of this structure is almost entirely protective, 
and that it plays but an unimportant part in the transmission 
of sound vibrations. That portion of the conducting tract 
which it separates from the outer world communicates with 
the surface of the body by means of the Eustachian tube ; it 
seems wiser, therefore, to consider the external and middle 
ear and Eustachian tube together, rather than as individually 
distinct, since they perform a single function. 

(3) 



4 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

The second portion, the receptive mechanism, includes not 
only the internal ear, or labyrinth, but, in addition, the trunk 
of the auditory nerve, its central and cortical nuclei and fibres 
of association and projection. The labyrinth, then, represents 
but a small portion of the receptive mechanism, constituting 
the specialized end organ of the auditory nerve, through 
which vibrations in the labyrinthine fluid produce specific 
impressions upon the cerebrum. It can be seen at once how 
much more comprehensive the range of aural pathology be- 
comes when this view is taken, than when anatomical divisions 
alone are followed. 



I. The Conducting Apparatus. 

Under this head we include the auricle and the cartilag- 
inous meatus, the bony external auditory meatus, the mera- 
brana tympani, the tympanum, and the Eustachian tube. 

The auricle and the cartilaginous meatus together form an 
irregularly funnel-shaped device for transmitting aerial vibra- 
tions to the deeper parts, the auricle constituting the wide 
portion of the funnel, the cartilaginous meatus the tubular 
portion. 

The Auricle. — The auricle consists of a thin plate of fibro- 
cartilage, oval in outline, attached to the side of the skull 

at an acute angle 
with the median an- 
teroposterior verti- 
cal plane of the body. 
Its posterior surface 
is convexand smooth, 
while the concave 
anterior surface pre- 
sents certain irreg- 
ularities which merit 
special description. 
The unattached bor- 
der of this oval car- 
tilaginous plate is 
folded forward upon 
itself to such an ex- 
tent that the free 
margin appears upon the anterior or external surface, form- 
ing the helix. Above, the helix does not terminate at the 



Crista 

helicis 



Spina 
helicis 




Fig. i.- 



-The cartilaginous framework of the auricle. 
(After Politzer.) 



THE AURICLE. 




Helix 



Antitragus. 



Fig. 2. — The auricle. 



supero-anterior attachment of the auricle, but is continued 
backward and slightly downward from this point, as a promi- 
nent ridge, the crista helicis, which forms the superior 
boundary of the cartilaginous meatus. 

At the base of the crest a minute spur of cartilage ex- 
tends downward, constituting the spina helicis. Followed in 
the opposite direction, the 
helix is seen to terminate 
in an elongated cartilagi- 
nous process, the processus 
caudatus; the spine of the 
helix and the caudate pro- 
cess can rarely be recog- 
nized on the living subject, 
but are discernible upon 
the cadaver after carefully 
removing the integument 
covering the auricle (Fig. 

o- 

The groove beneath the 
helix is called the fossa of 
the helix, or scaphoid fossa. Immediately in front of this 
fossa is a broad convex ridge running parallel to the helix 
called the antihelix, dividing above into two branches — the 
crura helicis or the crura furcata. These crura inclose be- 
tween them the fossa of the antihelix. The antihelix termi- 
nates below in a cartilaginous prominence — the antitragus. 
Immediately in front of the antihelix and extending down- 
ward as far as the antitragus is a deep cavity called the con- 
cha; this depression is partially divided by the spine of the 
helix into two unequal parts, of which the superior is the 
smaller and lies between the spine of the helix and the ante- 
rior crus of the antihelix, while the larger division lies in 
front of the antihelix and above the antitragus. As already 
stated, the superior margin of the cartilaginous meatus is 
formed by the spine of the helix ; its posterior and inferior 
margins constitute the anterior and inferior boundaries of the 
concha. In front of the entrance to the meatus, slightlv cov- 
ering it and continuous with its anterior wall, there is a 
prominent cartilaginous tubercle, somewhat pyramidal in 
shape, called the tragus. This is separated from the anti- 
tragus by a deep broad notch, the fissura intertragica. The 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



tragus is not completely separated from the antitragus by this 
fissure, the bases of the two processes becoming continuous at 
the junction of the anterior and inferior walls of the cartilag- 
inous meatus. Above, the tragus is completely separated 
from the spine and crest of the helix, the intervening space 
being filled with dense connective tissue. 

From the preceding description, it will be seen that while 
the contour of the cartilaginous margin of the auricle above, 
anteriorly and posteriorly, is fairly regular, its inferior margin 
from the processus caudatus of the helix to the fissura inter- 
tragica presents numerous irregularities of outline. These 
indentations are filled up by a mass of adipose connective tis- 
sue which, extending downward for a variable distance, gives 
a regular outline to the pinna. To this process the name of 
lobule is given. The walls of the irregular, funnel-shaped 
auricle, therefore, gradually converge to form the cartilagi- 
nous meatus. 

The Cartilaginous Meatus. — The lumen of this canal is 
oval in shape when viewed in cross section, the long axis of 

the ellipse being inclined at an 
angle of about sixty degrees to 
the horizontal plane. The in- 
ner extremity of this canal is 
attached by means of firm 
bands of connective tissue to 
the margin of the bony meatus. 
The cartilaginous framework 
of the canal is wanting above 
and posteriorly, this deficiency 
becoming greater as the canal 
extends inward, until at its ter- 
mination the inferior wall only 
is cartilaginous, being pro- 
longed for a short distance 
along the floor of the bony 
meatus as a tongue-shaped cartilaginous process, known as 
the processus triangularis * (Fig. 3). 

The wall of the canal is completed by firm connective tis- 
sue, which fills up the hiatus in its cartilaginous portion. This 
fibrous tissue is continuous with the periosteum of the corre- 




Fig. 3. — The cartilaginous meatus. 
(Politzer). c, Processus triangu- 
laris ; i, i, Incisures of Santorini. 



* Politzer, Zergliederung des menschlichen Gehororgans, 1889, p. 57. 



THE EXTERNAL MEATUS. 




sponding portion of the bony canal. The anterior wall of the 
cartilaginous meatus presents two vertical fissures (Figs. 3 
and 4) which pass completely through its substance. The 
spaces thus left are filled with connective tissue, with an 
occasional admixture of striped muscular fibres. These fis- 
sures are called the incisures of Santorini. The more extensive 
of the two is situated at the base of the tragus ; the second is 
farther inward, while a third is occasionally met with beyond 
this. These fissures ren- 
der the cartilaginous 
meatus more freely mov- 
able, and are important 
clinically, for through 
them deep abscesses of 
the parotid gland, dis- 
charging spontaneously, 
rupture into the canal 
on account of the weak- 
ness of the walls at this 
point. From a surgical 
standpoint these dehis- 
cences are important, 
since they enable us to 
turn the auricle and fibrocartilaginous canal forward on the 
cheek, after separation of the posterior, inferior, and superior 
attachments. 

The Bony Canal. — In order properly to understand the 
osseous meatus, it will be necessary to consider somewhat in 
detail the development of the temporal bone. This portion 
of the skull develops from four centers : the squamous, the 
petro-mastoid, the auditory or tympanic, and the stylomas- 
toid. This last center of ossification does not concern us, but 
the other three are of importance, as they are all integral parts 
of the auditory apparatus, and, with the exception of the pe- 
trous portion, all enter into the formation of the external 
meatus. The manner in which these various portion unite 
to form the temporal bone is shown in Fig. 5, which is some- 
what diagrammatic. 

The osseous meatus does not exist at birth, its place being 
supplied by a canal of fibrous tissue. Reference to Figs. 8. 
9, and 10, drawn from specimens prepared by the author. 
renders this clear. At its inner extremitv this terminates in 



Fig. 4. 



-a, a, The incisures of Santorini. 
(Urbantschitsch.) 



8 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

the auditory process or the tympanic ring. The auditory 
process (Figs. 5 [2] and 13 [III]) consist of a thin osseous strip 
bent in the form of an oval, the curvilinear outline being 
wanting for about an eighth of its circumference at the broader 




Fig. 5. — The development of the temporal bone. I, The squamous portion ; 5 T 
The tympanic ring ; 3, The petro-mastoid portion. The upper figure illustrates 
the union of the three portions. (Modified from Gray.) 



pole. The concave margin of this bony ring is grooved for 
the insertion of the membrana tympani, and is named the 
sulcus tympanicus, while the ring itself is called the annulus 
tympanicus. The free extremity of the posterior limb of the 
annulus is called the spina tympanica posterior or spina tym- 
panica minor. Just below the extremity of the anterior limb 
a bony spine projects backward, the spina tympanica major. 
The spina tympanica anterior is directed forward, and con- 
sists of a small bony tubercle lying just beneath the larger 
tympanic spine. 



THE BONY MEATUS. 



9 



The squamous portion of the temporal bone develops 
from a single center. Early in foetal life it consists of a flat 
osseous scale, presenting a ridge upon its outer surface, 
which afterward becomes the zygomatic process. Below the 
root of this process is a shallow excavation, the glenoid fossa. 
Behind this depression the bony plate divides into two la- 
mellae, the inner of which is directed almost horizontally 
inward and forms subsequently the roof of the tympanum 
and of the mastoid antrum. The external lamella passes 
downward and somewhat inward and exhibits a deep 
notch upon its inferior border. The annulus tympanicus 
joins the external plate of the squama by the union of the 
free extremities of its anterior and posterior limbs to the 
corresponding angles of the notch above described. The 
curvilinear outline of the ring is 
completed by the notched inferior 
border of the external plate of the 
squamous portion of the temporal 
bone. This is shown in Fig. 6. 
The circlet thus completed gives 
attachment to the inner extremity 
of the fibrous canal, which occupies 
the position of the future bony 
meatus. As development pro- 
gresses, the fibrous canal is replaced 
by osseous tissue. The annulus 
tympanicus is converted into a 
bony groove by ossification out- 
ward, and, as will be seen by consulting Figs. 8, g, and io„ 
the process effects simply the separation of the superior 
and inferior walls, which at birth are in contact. This gutter 
forms the anterior, inferior, and posterior walls of the bonv 
meatus, the superior wall being formed by that portion of 
the temporal bone which completes the osseous outline of 
the annulus tympanicus. 

In the adult temporal bone (Fig. 7) the deep groove formed 
by the outward growth of the annulus tympanicus is called 
the auditory process. It is separated in front from the squa- 
mous portion of the temporal bone by a narrow fissure called 
the Glaserian fissure ; posteriorly the auditory process enters 
into the formation of the mastoid squamous suture, its postero- 
superior termination constituting the spinum supra-meatum. 




Fig. 6. — Temporal bone of in- 
fant, natural size. (Author's 
collection. 



10 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

The external plate of the squama, which completes the out- 
line of the bony meatus, during development grows almost 




Fig. 7. — The adult temporal bone, natural 
size. (Author's collection.) 



directly outward in a horizontal direction, and nearly at right 
angles to that portion of the temporal bone lying above the 

zygomatic process. As previously 
stated, the fibrous tissue which oc- 
cupies the place of the bony meatus 
at birth is gradually replaced by 
bone, and this part of the meatus, 

J which at first was movable, be- 

; Ji BL comes bony and rigid. As a re- 

sult, the angle between the mem- 
brana tympani and the superior 
wall of the canal becomes appar- 
ently more acute as development 
advances. The actual angle of in- 
clination of the membrane with the 
horizontal plane probably does not 
change to any degree after birth. 
The line of demarcation between 
Fig. 8.— The external meatus and it and the superior wall is more 

membrana tympani of a child at ., , , , 1 «i i 

birth, natural size. The meatus easily made out in older children 

has been split, and the superior anc J ac }ultS, On account of the 
and inferior walls have been . 

held apart. (Author's specimen.) change taking place in the meatus. 




" : -s^>^*^ 



THE BONY MEATUS. 



II 



At birth the superior and inferior walls are in contact and 
must be separated in order to inspect the membrana tympani, 
as the specimen from which Fig. 8 was drawn shows. In 
this specimen the anterior wall of the canal was cut through, 
from just in front of the tragus to the membrana tympani, 
and the walls separated so that the parts could be seen and 
drawn. 

When we compare this drawing with Figs. 9 and 10, repre- 
senting the same region in childhood and adult life, we see 
at once that the formation of the bony canal may be said to 
have effected this separation and made it permanent, simply 
by the deposit of bony tissue, rendering the fibrous tube rigid. 





Fig. g. — External meatus, membrana tym- 
pani, and middle ear from a child five 
years of age, natural size. (Author's 
specimen.) 



Fig. 10. — Sagittal section through ex- 
ternal auditory meatus, membrana 
tympani, and middle ear of an adult, 
natural size. (Author's collection.) 



The third portion of the temporal bone, the petro-mastoid 
part, consists of an oblique triangular osseous pyramid, the 
apex of which is directed forward and inward, while its base 
fills up the gap between the free margin of the squamous 
plate of the temporal bone and the posterior crus of the 
annulus tympanicus, at the same time extending forward, so 
that the anterior portion of this surface lies opposite the tym- 
panic ring. 

The line of union of the mastoid portion to the external 
squamous plate is the mastoid squamous suture. Looking at 
the cranial surface, we find that the petrous portion unites 



12 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

with the inner plate of the squama, forming the petrosqua- 
mous suture. 

It is clear from the foregoing description that the base of 
the pyramid is made up of the outer surface of the mastoid 
and of that portion of the petrous bone lying below the petro- 
squamous suture and opposite the tympanic ring. This last 
region corresponds to the inner wall of the tympanic cavity, 
or the fundus of the external auditory meatus, the membrana 
tympani having been removed. 

The Tympanic Cavity. — The tympanic cavity is a bony 
chamber the inner wall of which is formed by the external 
surface of the petrous portion of the temporal bone. This 
wall (Fig. n) presents for inspection a rounded eminence, 

called the promontory, covering 
the first turn of the cochlea. Be- 
hind, and somewhat beneath the 
promontory, there is a niche called 
stapes. EdmJ3g*^*': j "V the niche of the round window, 




Rou . n ^ Hr^ ' V '-£* .- -^ into which the fenestra rotunda 

window. Finirr diTtoirfflh - MtB g^'l 

opens. This niche looks almost 
directly backward, and even when 
the parts are most favorably dis- 
posed for inspection, but a very 

Fl %ar[A h u e tho"'r s n p a e 1 cim y en P ) aniC limited ^ ° f the depression is 

visible. Above, in the upper and 
posterior portion of the inner wall, is an oval fossa, the pelvis 
ovalis, at the bottom of which is the oval window. In Fig. 
ii the stapes is in position, and fills the pelvis ovalis. The 
posterior wall of the pelvis ovalis is abrupt, while its anterior 
wall slopes gradually forward until it merges into the sur- 
face of the promontory. The inferior wall is longer and 
more precipitous that the superior wall. The lumen of the 
fenestra ovalis looks outward and downward. At birth the 
pelvis ovalis is separated from the niche of the round win- 
dow by a deep fossa, the sinus tympanicus (seen in Fig. 6), 
which usually disappears completely in adult life. Above 
the oval window there is a distinct bony arch formed by the 
encroachment of the outer wall of the aqueductus Fallopii 
upon the tympanic cavity. The facial nerve passes through 
this canal. Directly above this bony ridge there is another 
and smaller bony crest, caused by the projection of the hori- 
zontal semicircular canal outward into the cavity of the 



THE TYMPANIC CAVITY. 



13 



middle ear. The outer wall of the aqueductus Fallopii is 
occasionally incomplete, the facial nerve being then exposed 
in its passage through the tympanum. Behind the pelvis 
ovalis, at the juncture of the inner and posterior walls of the 
tympanum, there is a small bony pyramid, through the apex 
of which the tendon of the stapedius muscle passes. The 
plane of the inner wall of the tympanic cavity lies more 
nearly in the median antero-posterior vertical plane of the 
body than does that of the tympanic ring; hence the tym- 
panic cavity is broader above and posteriorly, than below 
and anteriorly. In front of the promontory the inner wall is 
smooth and gradually merges into the tympanic opening of 
the Eustachian tube. 

The anterior wall of the tympanum presents at about its 
centre, the tympanic orifice of the Eustachian canal. Above 
this, and separated from it by a thin bony plate, the proces- 
sus cochleariformis, is the canal for the tendon of the tensor 
tympani muscle. The anterior wall is separated from the in- 
ternal carotid artery as it passes through the carotid canal 
by a thin, bony plate. The osseous floor of the cavity lies at 
a considerable distance below the lower margin of the tym- 
panic ring. It is sometimes formed of fairly compact bone, 
but quite frequently it is cancellous ; it is in relation with the 
jugular fossa, which lodges the bulb of the internal jugular 
vein, and may present dehiscences, exposing the bulb to trau- 
matism by instruments introduced into the meatus. 

The posterior wall presents, at its junction with the inter- 
nal wall, the pyramid, through the apex of which the tendon 
of the stapedius muscle passes. The opening into the mastoid 
antrum lies directly above this process. The external wall of 
the tympanum is formed chiefly by the membrana tympani 
(a structure which will be described presently), by the inner 
surface of the tympanic ring, and above by the inner margin 
of the external plate of the squama and by the angle formed 
by the separation of the inner and outer plates. It becomes 
evident, therefore, that the tympanic cavity is prolonged up- 
ward for a considerable distance above the plane of the supe- 
rior wall of the meatus. This portion of the cavity is the 
epitympanic space or recess, or the vault of the tympanum. 
The portion lying below this plane is called the atrium. 

The Vault of the Tympanum (Fig. 12). — The epitympanic 
space is somewhat pyramidal in shape, the apex lying at the 



14 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 




angle between the two plates of the squama. These plates, 
with the adjoining portions of the petrous bone and the petro- 
squamous suture, complete two 
osseous faces of the pyramid ; 
the remaining surface and the 
base are partly wanting, being 
represented by the openings 
leading into the mastoid antrum 
posteriorly, and into the tym- 
vA panic cavity below. When the 
parts are in their normal posi- 
tion this lower surface is par- 

riG 12. — The internal tympanic wall . L 

and the vault of the tympanum, tially completed by the ossicula, 
with the ossicles in position. (Au- th ir ligaments, and the redu- 

thor s collection.) & 

plications of the mucous lining 
of the tympanum, which shut off the upper portion of the 
cavity more or less perfectly from the lower part. 

The Ossicles (Figs. 13 and 14). — The ossicular chain is 
lodged within the tympanum, and serves to transmit and 
modify sound vibrations. It constitutes, in reality, a lever 
through which the impulses transmitted to the labyrinthine 
fluid are increased in intensity, but diminished in amplitude. 

The ossicles are three in number : the malleus, incus, and 
stapes. According to Rathke* and Urbantschitsch,f the 
malleus and incus are developed from one nucleus, and sub- 
sequently become separate bones, intimately connected at 
their articular surfaces, while the stapes develops from a dis- 
tinct centre of its own. 

Gradenigo J believes that the foot plate of the stapes 
springs from the capsule of the labyrinth, while the remain- 
der develops from the second visceral arch, the two portions 
subsequently uniting. 

The Malleus. — The malleus is the largest ossicle of the 
series, and consists of a head and shaft joined to each other at 
an obtuse angle by a constricted portion called the neck. The 
shaft or long process is prismatic on cross section, and tapers 
gradually from just below the neck of the ossicle to the tip, 
which is sometimes bent slightly forward in the form of a hook. 



* Kiemenapp. und Zungenb., 1832, p. 122. 
f Lehrb. der Ohrenheilk., Wien, 1890, p. 229. 
X Med. Jahrbuch, Wien, 1887. 



PLATE I. 




Fig. A. — Anatomical Plate. 
View of tympanic ring, internal wall of middle ear, and malleus and incus as seen 
from without. The nitch of the round window is easily recognized below the 
long process of the incus. (Author's specimen.) 




Fig. B. — Anatomical Plate. 

Bony specimen showing superior horizontal and posterior semicircular canals, and 

the facial canal. (Authoi's specimen.) 



PLATE II. 




Fig. 



Plate. 



A. — Anatomical 

Section through middle ear. D, Stapes ; above the stapes is seen the canal for the 
facial nerve. This canal is seen to pass downward through the substance of the 
mastoid process. A, Membrana tympani. £, Head of malleus. C, Body of 
incus. (Author's specimens.) 




Fig. B. — Anatomical Plate. 
Section through temporal bone, showing mastoid, facial canal, and internal wall of 
middle ear. A, Head of stapes. £, Promontory covered with branches of 
tympanic plexus. C, Facial canal. (Author's specimen.) 



THE OSSICLES. 1 5 

At the junction of the shaft with the neck there is a prominent 
bony tubercle called the short process of the malleus, which 
is directed forward and outward. The prismatic shaft pre- 
sents an external border for attachment to the membrana 
tympani, an internal border directed toward the labyrinthine 
wall, and somewhat broad anterior and posterior surfaces. It 
is evident that any rotation of the malleus upon the long axis 




Fig. 13. — The ossicles and the annulus tympanicus. I, Ossicular chain of left ear. 

1, Malleus ; 2, Incus ; 3, Stapes. II, Ossiculus chain of right ear. 1, Malleus ; 

2, Processus folianus ; 3, Manubrium ; 4, Long process of incus ; 5, Short process 
of incus ; 6, Stapes. Ill, Annulus tympanicus. 1, Anterior tubercle ; 2, Pos- 
terior tubercle. (Rudinger : Blake's translation.) 

of the manubrium will alter the apparent breadth of the shaft 
as viewed through the meatus, according as the degree of 
rotation brings the broad anterior or posterior surface into 
view, or the sharp edge which marks the junction of these 
surfaces with the anterior border. Springing from the an- 



i6 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



terior surface just below the short process is a long-, delicate, 
bony spicule, the processus folianus or gracilis, which lies in 
the Glaserian fissure, and in adult life is frequently imbedded 
in the fibres of the anterior ligament. The external surface 
of the neck of the malleus is roughened for the attachment of 
the external ligament. The anterior surface of the neck and 




Tig. 14. — The malleus, incus, and stapes in various positions. (Rudinger : Blake's 

translation.) 



the adjoining portion of the head are deeply grooved for the 
insertion of the anterior ligament. The head is irregularly 
spherical in shape, the spherical contour being encroached 
upon posteriorly by the saddle-shaped surface for articulation 
with the incus, while anteriorly there is a groove for the at- 
tachment of the anterior ligament. 



THE OSSICLES. \j 

The Inctis. — The central ossicle of the chain consists of a 
body and two processes. The short or horizontal process — a 
continuation of the body — is conical in shape and extends 
backward, its tip resting in a little pit or fossa in the posterior 
tympanic wall, just below the entrance to the mastoid antrum. 
This depression is called the sella incudis. The body of the 
bone is flattened from before backward, the vertical diameter 
being about double the transverse. The anterior surface, 
forming the base of the cone, is saddle-shaped for articulation 
with the malleus. The long or descending ramus of the incus 
is a long, tapering bony shaft, extending downward from the 
antero-inferior angle of the body ; its lower extremity is bent 
inward so that the tip of the process is directed toward the 
internal tympanic wall. This free extremity is called the len- 
ticular process, and articulates with the head of the stapes. 
The lenticular process in fcetal life is represented by a sepa- 
rate bone, the os orbiculare. . 

The Stapes. — The innermost ossicle of the series brings the 
conducting mechanism into immediate relation with the re- 
ceptive apparatus. As the name implies, it is stirrup-shaped, 
and consists of a small rounded head the external face of 
which is hollowed out for articulation with the lenticular pro- 
cess of the incus ; below the head is a constricted portion 
called the neck, from which the crura diverge. The posterior 
crus is the longer and more curved. The crura terminate in 
an oval or kidney-shaped plate of bone, the foot-plate of the 
stapes, which closes the oval window. The entire stapes lies 
almost wholly within the pelvis ovalis, hence when the mem- 
brana tympani is wanting it is well protected from traumatism 
from instruments introduced through the canal. The stapes 
lies obliquely in the oval niche, being nearer to the inferior 
and posterior walls of the fossa than to the anterior and supe- 
rior. Since the posterior wall of the niche is almost vertical, 
the corresponding stapedial crus lies close to it, and adhesions 
between this wall and the posterior limb of the ossicle are of 
frequent occurrence. 

The ossicular chain is suspended in the tympanic cavity 
by a series of ligaments which bind the individual members 
of the chain to each other and to the walls of the tympanum. 

Ligaments of the Malleus (Fig. 15), — These are four in 
number : the anterior, external, posterior, and superior or sus- 
pensory ligament. 

3 



1 8 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

The anterior ligament is the strongest of these. It arises 
from the spina tympanica major and from the walls of the 
Glaserian fissure, some of the fibers traversing the length of 
the fissure and taking their origin from the spine of the sphe- 



% 

Mastoid jBBa*.- ,. External ligament. 

antrum. 




Anterior ligament. 



Stapes. 

Tendon of ten- 
sor tympani. 

Fig. 15. — The tympanum from above. (Author's specimen.) 

noid. From this extensive origin they pass outward, upward, 
and backward, and are inserted into the anterior surface of 
the neck of the malleus and into the depression found on the 
anterior surface of the head. They inclose the processus 
folianus of the malleus. 

The external ligament is somewhat fan-shaped. It springs 
from the external roughened surface of the neck of the ossicle, 
from which point the fibers diverge to be inserted into the 
free margin of the inner extremity of the superior wall of that 
portion of the bony meatus formed by the external plate of the 
squama. The posterior fibres, according to Helmholtz, form 
a distinct band called the posterior ligament of the malleus.* 

This portion of the external ligament, together with the 
anterior ligament, forms the axis band of the hammer, since 
the axis of rotation of the ossicle is approximately a line drawn 
through the attachment of these two ligamentous structures. 

The superior ligament is a delicately rounded band of 
fibrous tissue running from the tegmen tympani downward 
to the head of the malleus. 

The Ligaments of the Incus. — The incus is bound to the 
tympanic wall by a single fibrous band, the posterior liga- 

* The Mechanism of the Ossicles, Translated by Buck and Smith, New York, 
1873. 



THE INTRATYMPANIC LIGAMENTS. 



19 



merit, which extends from the lateral aspects of the short 
process near its extremity to the posterior wall of the tym- 
panum. At its origin it is dense in structure, owing to the 
somewhat limited area from which it arises. From this point 
the fibres diverge rapidly and divide into two bundles to be 
inserted into a broad area on the posterior wall of the tym- 
panum. On account of this broad insertion it is sometimes 
called the fan-shaped ligament of the incus. The inferior sur- 
face of the short process lies in a shallow depression in the 
tympanic wall called the sella incudis, the opposing surfaces 
being covered with cartilage. 

The Ligaments of the Stapes. — The foot plate of the 
stapes is confined in the oval window by the stapedio-ves- 
tibular or annular ligament. The margins and vestibular sur- 
face of the foot plate and the periphery of the oval window 
are covered with hyaline cartilage, the annular ligament de- 
veloping from the perichondrium. 

Interossicular Ligaments. — The malleus and incus are 
bound together by a loose capsular ligament, the articular 
surfaces of the ossicles being covered with cartilage. The 
incudo-stapedial articulation is similar in character. 

The Eustachian Tube. — Having traced the bony and car- 
tilaginous framework of the conducting mechanism inward 




Fig. 16. — Section through mastoid, tympanum, and Eustachian tube. (Politzer.) 
W, W, Mastoid cells; mt, Membrana tympani ; an, Antrum ; n, Vault of tym- 
panum ; it, Isthmus of tube ; te, Eustachian tube ; op, Pharyngeal orifice of 
tube. 



to the point where it joins the receptive portion of the audito- 
ry apparatus at the oval window, we have next to consider 
the characteristics of that passage bv means of which certain 
delicate parts of this system can be protected bv a fibrous 



20 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

covering without interfering- with the transmission of sound 
waves. By means of the canal now to be described an equal 
atmospheric pressure is maintained upon either side of this 
protecting septum. This passage is the Eustachian tube. It 
is made up of two portions — the tympanic or bony, and the 
pharyngeal or cartilaginous portion — their point of junction 
being called the isthmus of the tube. The osseous segment 
is about half an inch in length, and, extending from a 
somewhat wide orifice just above the middle of the internal 
wall of the tympanum, narrows quickly as it passes down- 
ward, forward, and inward through the substance of the pe- 
trous portion of the temporal bone, until at the isthmus its 
diameter varies from one twenty-fifth to one twelfth of an 
inch. The canal is irregularly triangular in shape, the verti- 
cal diameter being double the transverse. This osseous tube 
is joined at the isthmus to the cartilaginous portion by fibrous 
tissue, the parts uniting at an obtuse angle, the opening of 
which is directed downward and forward. The pharyngeal 
portion measures about an inch in length, and at the isthmus 
its lumen corresponds to that of the osseous channel. As it 
extends downward into the pharynx, however, it grows wider, 
and at the pharyngeal orifice measures from one eighth to 
one fifth of an inch in diameter, the vertical diameter being 
greater than the transverse. This portion of the canal is 
fibrocartilaginous. The posterior wall 
^iBlk * s f° rme d by a plate of cartilage, the 

upper border of which is bent first 
forward and then downward, so that 
a transverse section would be hook- 
shaped (see Fig. 17). The space in- 
closed by the bending forward of the 
f#\ cartilage forms the superior portion of 

t§S%^ tne lumen of the tube, the interval be- 

- ^ tween the free margin of the angular 

portion and the lower border of the 
£i cartilaginous plate being filled with 

Fig. 17.— Transverse sec- fibrous and muscular tissue, thus com- 

tion of Eustachian tube. •, „_• ^, i TTr ,, r 

(After Zuckerkandi.) pleting the canal. We see, therefore, 

that the posterior, superior, and a small 

portion of the anterior wall of the tube is cartilaginous, while 

the remainder of the anterior and entire inferior wall is 

fibrous, the passage being slitlike rather than circular on cross 



THE MEMBRANA TYMPANI. 21 

section, with the anterior and posterior walls in contact except 
at the upper part. The membranous tube is attached to the 
inner extremity of the bony canal, the posterior cartilaginous 
plate uniting with a prolongation of the corresponding bony 
wall. Beyond the isthmus the tube is suspended from the 
base of the cranium by fibrous bands passing to its superior 
wall, until it terminates in the lateral aspect of the pharyngeal 
vault. 

As described in the foregoing pages, the conducting 
mechanism consists of a canal, the walls of the central por- 
tions being osseous, while at either extremity they are fibro- 
cartilaginous, communicating upon one side with the outer 
surface of the body directly, while upon the other this com- 
munication is effected indirectly through the oral and nasal 
passages. This tube is brought into intimate relation with 
the receptive mechanism through the agency of the ossicular 
chain, and at this point the osseous conduit is dilated, forming 
the tympanum. This chamber, situated midway in the pas- 
sage, is occupied by a special device for bringing the two 
portions of the auditory apparatus into relation with each 
other. For the protection of the intratympanic parts chiefly, 
and, to a certain extent, to aid in the transmission of sonorous 
impulses, a fibrous partition divides the external auditory 
meatus from the tympanum and Eustachian tube. This parti- 
tion constitutes the membrana tympani. 

The Membrana Tympani. — The membrana tympani con- 
sists of a transverse fibrous septum, lying in the middle of the 
conducting tube, and bounded by the tympanic ring, which, 
it will be remembered, is incomplete at its upper part. This 
connective-tissue lamella, called the substantia propria of 
the drum membrane, is inserted into the sulcus tympanicus. 
At the point of insertion the fibrous tissue is somewhat thick- 
ened, forming the annulus tendinosus, sometimes called the 
cartilaginous ring. From the cartilaginous ring certain 
connective-tissue fibres extend outward to the periosteum of 
the meatus, while others, passing in the opposite direction, 
merge into the periosteal lining of the tympanum. The sub- 
stantia propria is made up of two layers. In the outer layer 
the fibres radiate from the tip of the malleus toward the 
peripheral wall, while in the internal layer they are disposed 
in concentric circles about this point as a centre. The manu- 
brium of the malleus joins the substantia propria through the 



2 2 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

interposition of a thin cartilaginous lamella which extends 
along its outer border from the processus brevis to the umbo, 
the fibres of the membrane being continuous with the peri- 
chondrium of this cartilaginous plate. At the tip of the 
manubrium both the circular and radiating fibres are attached 
directly to the ossicle, while above this point, along the ex- 
ternal border, the attachment is effected through the interpo- 
sition of the cartilaginous plate above described. This carti- 
lage is firmly fixed at the tip of the manubrium, while the 
attachment at the short process is less firm and permits of a 
certain amount of separation from the short process. The 
superior border of the lamina propria joins the anterior and 
posterior extremities of the annulus tympanicus, constituting 
a tense, fibrous band, divided by the short process of the mal- 
leus into two parts. The sharply defined superior margin of 
the membrana propria extending from the processus brevis to 
the posterior extremity of the annulus is called the posterior 
fold The corresponding anterior fold is less prominent and 
shorter than the posterior. From the description it will be 
observed that the fibrous septum stretched across the canal 
is wanting where the curved outline of the annulus is com- 
pleted by the auditory plate of the temporal bone. This 
space is the Rivinian segment or notch, and its closure will 
be explained later, since it is effected by the cutaneous lining 
of the external auditory meatus. 

The Epithelial Investment of the Conducting Apparatus. 
— The auricle is covered with integument which is continuous 
with that of the face. It is somewhat loosely attached upon 
the posterior surface, but upon the anterior aspect is applied 
closely to the cartilage, the deep layer being intimately asso- 
ciated with the perichondrium. The tegumentary covering 
of the auricle is continued into the external auditory meatus, 
its thickness decreasing as we pass inward, until in the bony 
canal its deep layer forms the periosteum. The cutaneous 
lining of the meatus along the supero-posterior wall is thick- 
er and more loosely attached than elsewhere, and is richly 
supplied with blood vessels. The covering of the superior 
wall of the canal passes from the internal margin of the audi- 
tory plate to the neck of the malleus, just above the short 
process, filling up the Rivinian notch and completely sepa- 
rating the external meatus from the tympanum. In com- 
parison with the remaining portion of the membrana tym- 



THE EPITHELIAL INVESTMENT. 23 

pani, it hangs somewhat loosely from the canal wall, and is 
called the membrana flaccida, or Shrapnell's membrane. Its 
fibrous layer is particularly well developed along the anterior 
and posterior borders, causing it to assume a somewhat tri- 
angular shape. These distinct fibrous bands constitute the 
fibres of Prussak. They extend from the anterior and pos- 
terior extremities of the Rivinian segment to the base of the 
processus brevis, and, passing along the manubrium, are lost 
in the external layer of the membrana propria. The space 
between the anterior ligament and the membrana flaccida is 
called Prussak's space. The epithelial covering of the meatus 
continues over Shrapnell's membrane, and covers completely 
the external surface of the drum membrane, forming its ex- 
ternal or epithelial layer. The auricle, the meatus, and the 
superficial layer of the membrana thus constitute an elon- 
gated blind pouch, not unlike the finger of a glove, the drum 
membrane answering to the closed tip of the glove finger. 

The integument of the auricle is supplied with sweat 
glands and sebaceous follicles. In the region of the tragus 
and antitragus, and for some distance within the cartilaginous 
canal, hair follicles are frequently found. The sebaceous 
glands in the meatus are somewhat altered in structure, con- 
stituting the ceruminous glands. These are not distributed 
beyond the junction of the cartilaginous meatus with the 
osseous portion, except for a small area along the upper and 
posterior wall, where they encroach slightly upon the bony 
canal. The glands are larger upon the upper wall of the canal, 
and are most numerous at the junction of the bony with the 
fibro-cartilaginous portion. 

The tympanum and Eustachian tube are lined with mu- 
cous membrane continuous with that of the naso-pharynx. 
This membrane extends outward through the tube, covering 
its walls and forming the lining of the tympanum. It passes 
over the internal surface of the membrana tympani, constitut- 
ing its internal layer ; in various localities it is folded upon 
itself as it passes over the various intratympanic structures, 
giving rise to the so-called reduplications of mucous membrane 
within the tympanum. The most constant of these reduplica- 
tions constitute the anterior and posterior pockets of the mem- 
brana (Fig. 18), while other folds whose location and disposi- 
tion are not as constant are also met with. The lining in the 
cartilaginous portion of the Eustachian tube is thick and loose- 



24 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

ly attached, being thrown into longitudinal folds in the lower 
part. In the osseous tube and tympanum it is closely applied 
to the underlying structures constituting the periosteum. The 
epithelium is of the cylindrical ciliated variety in the tube and 
in the lower portion of the tympanic cavity, according to Po- 
litzer,* it changes to flat, ciliated epithelium above. 

The mucous membrane is supplied with mucous glands, 
which are extensively developed in the cartilaginous tube near 
the pharyngeal orifice, and diminish in number in the bony 
tube and tympanic cavity. In the middle ear they are mostly 
confined to the tubal orifice, although they are occasionally 
found over the promontory. The membranous portion of the 
Eustachian tube is quite richly supplied with lymphatic tissue, 
which occurs both in the diffuse form and, aggregated into 
masses, in the form of true lymphatic nodules. To these 
Gerlachf gives the name of tubal tonsil. The presence of 
this lymphatic tissue has also been demonstrated by Sappey,^ 
Ostmann,* and Teutleuben.| 

The Pockets of the Membrana Tympani and other Reduplica- 
tions of the Mucous Membrane (Figs. 18 and 19). — The pockets 
of the membrana tympani are the most constant of the re- 







^ 


p 


y. 18. — The pockets of 
the membrana tym- 
pani. (After Zuck- 
erkandl.) 



W." 

Fig. 19. — The malleo - incudal 
articulation covered by the 
superior malleo-incudal fold. 
(After Zuckerkandl.) 

duplications which the lining of the cavity forms. The mu- 
cous membrane lining the tympanum is attached firmly to the 
drum membrane, to the bony internal wall, and to the walls 
of the irregular spaces which lie between the membrana tym- 
pani and the structures contained within the middle ear and 
in immediate relation with the membrane. After being re- 
flected over the contiguous bony and ligamentous parts it 

* Lehrb. der Ohrenheilk., Wien, 1893, p. 28. 
f Arch, fur Ohren., vol. x, p. 53. 

\ Traits d'anatomie descriptive, Paris, 1877, p. 865. 

* Virchow, Archiv, vol. xxxiv. 

|| Zeit. fiir Anat. und Entwicklungsgeschichte, 1876, vols, iii and iv, p. 298. 



INTRATYMPANIC FOLDS. 25 

hangs downward into the tympanic cavity in folds somewhat 
like a curtain. The free borders of these folds are sharply 
marked and constitute the folds of the pockets. The anterior 
fold lies in front of the malleus, and the posterior behind it. 
The anterior pocket is the space included between the neck 
of the malleus behind, the annulus tympanicus in front, the 
membrana tympani on the outer side, and the spina tym- 
panica major and the anterior ligament on the inner side. At 
its apex it sometimes communicates with the chamber of 
Prussak. The posterior pocket is larger, and is traversed by 
the chorda tympani nerve and the posterior ligament of the 
malleus. Its free border — the posterior fold — may extend 
downward as far as the middle of the manubrium. This is a 
point of practical importance in middle-ear operations, since 
after the division of the membrana tympani, this fold, if ex- 
tensive, may completely hide the incus, to the long process of 
which it is frequently firmly attached. I have met with this 
condition several times, and unless one remembers the possi- 
bility of such an anomaly, its presence may prove a source of 
annoyance. In one case of exploratory tympanotomy per- 
formed under local anaesthesia, the posterior fold was long, 
thick, and adherent to the descending arm of the incus and 
to the membrana tympani. An incision through the mem- 
brana, instead of exposing the incudo-stapedial articulation, 
brought into view a thick vascular lamella of mucous mem- 
brane which demanded repeated incision before the long arm 
of the incus could be recognized or the inner wall of the tym- 
panum seen. In another instance the fold was thin, but in- 
vested the incudo-stapedial articulation and long arm of the 
incus so completely that exploratory tympanotomy revealed, 
immediately after displacement of the flap, nothing but a 
smooth, glistening surface, which appeared to be the inner 
wall of the middle ear. No landmarks could be made out ; a 
fact which showed that the inner tympanic wall had not been 
exposed, and it was not until the mucosa was divided by a 
vertical incision that the promontory and the niche of the 
round window could be seen. In acute inflammatory condi- 
tions I have seen exudation encapsulated in the tympanum 
on account of an anomaly in the posterior pocket. The boun- 
daries of the posterior pocket will be made clear bv bearing 
in mind those of the anterior space, its exact analogue. 

The other mucous folds within the tympanum will not be 



26 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

described in detail on account of their endless variety, but a 
general account of their usual position and direction is neces- 
sary, since their presence is often of great importance both as 
affecting the outcome of inflammatory processes within the 
tympanum, and increasing the difficulty of certain operative 
procedures. These folds differ from the true ligaments only 
in their density. They have been extensively studied by 
Blake,* Bryant, f Zuckerkandl,^ and others. 

In general they may be classified, according to their direc- 
tion, as vertical or horizontal, and according to their situation* 
as those radiating from the axes of the long bones, those dis- 
posed about the stapes and the adjoining tympanic walls, and 
those stretching from the ossicular ligaments and the tendons 
of the intratympanic muscles to the ossicles and to the tym- 
panic walls. The horizontal folds may completely shut off the 
vault of the tympanum from the atrium, and the vertical folds 
may be so extensive as to inclose the entire ossicular chain 
except the manubrium of the malleus. 

The horizontal folds exert an important influence on acute 
and chronic inflammatory processes within the middle ear, 
their presence favoring the invasion of the mastoid process 
and cranial contents. The vertical folds not only act as ob- 
structors to the conduction of sound by their weight and by 
the increased tension which they cause, but are of great an- 
noyance to the surgeon in the performance of delicate opera- 
tions upon the tympanum, as they may completely hide 
important structures. Their presence, therefore, should be 
borne in mind in the consideration of all pathological pro- 
cesses within the middle ear, as in this way many appear- 
ances which are otherwise inexplicable may be correctly 
interpreted, or an operator may be able to accomplish an end 
which a hasty view of the cavity had led him to believe 
would be impossible. It need only be remembered that no 
hard-and-fast rule can be given for their location, and that 
almost any of the folds may occur together. 

The Muscles. — The muscles of the conducting mechanism 
include those passing from the auricle to the skull, the in- 



* Arch, of Otol., vol. xix, p. 209. 

f Ibid., p. 217. Burnett's System of Diseases of the Ear, Nose, and Throat, 
Philadelphia, 1893, vol. i, p. 55. 

% Schwartze's Handbuch der Ohrenheilk., Halle, 1893, vol. i, p. 21. 



THE MUSCLES. 2J 

trinsic muscles of the auricle and canal, the intratympanic 
muscles, and those in the walls of the Eustachian tube. 

The auricle is bound to the skull posteriorly by the mas- 
toid fascia, the fibres of which interlace with the perichon- 
drium and fibrous tissue of the canal, and anteriorly by the 
temporal fascia, which is firmly attached to the helix. 

The extrinsic muscles are three in number, and are unim- 
portant in man, though in some of the lower animals they 
reach a high degree of development. They are the retrahens 
aurem, attollens aurem, and attrahens aurem. 

The retrahens arises from the mastoid region by short 
aponeurotic fibres, and is inserted into the cartilage of the 
auricle upon its posterior and inferior aspect. Its point of 
origin is fixed only when the occipital portion of the occipito- 
fron talis is rigid. 

The attrahens arises from the epicranial aponeurosis at its 
lower border, and is inserted into the spine of the helix upon 
its cranial surface. 

The attollens arises from the occipito-frontalis aponeuro- 
sis. The fibres converge to the point of insertion upon the 
upper part of the cranial surface of the auricle. 

The intrinsic muscles consist of poorly developed bundles 
of muscular fibres distributed between the various cartilagi- 
nous processes of the auricle. Theoretically, their action 
would serve to alter the shape of the pinna, but from their 
imperfect development they are unimportant. They are 
situated chiefly upon the external surface of the organ. In 
the external meatus a few fibres of muscular tissue are found 
mixed with the fibrous bands which fill the incisures of San- 
torini. 

A muscular slip is occasionally found extending from the 
styloid process upward to the cartilaginous meatus. 

The intratympanic muscles are the tensor tympani and the 
stapedius. 

The tensor arises from the upper wall of the cartilaginous 
Eustachian tube and from the walls of the bony canal which 
inclose it. It enters the middle ear through an osseous con- 
duit at a point just above the tympanic orifice of the Eu- 
stachian tube, from which it is separated bv a thin plate of 
bone — the processus cochleariformis. The tympanic extrem- 
ity of this process is pyramidal in shape, and is often called 
the anterior pyramid. The tendon winds about this projec- 



28 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

tion almost at a right angle, crosses the cavity of the middle 
ear, and is inserted along the inner border of the shaft of the 
malleus just below the neck, some of the fibres passing for a 
considerable distance down the manubrium, and spreading 
somewhat upon its anterior surface. 

The stapedius arises from the interior of the pyramid 
found upon the postero-internal tympanic wall in front of 
and below the aqueductus Fallopii. The fibres converge 
into a tendon which pierces the apex of the pyramid and is 
inserted into the neck of the stapes at the point of union with 
the posterior crus. 

The muscles of the Eustachian tube are the tensor palati, or 
spheno-salpingo-staphylinus, and the levator palati, or petro- 
salpingo-staphylinus. 

The tensor palati exerts the most influence upon the lumen 
of the Eustachian canal. It arises from the scaphoid fossa 
and spine of the sphenoid bone in front of the membranous 
portion of the tube, some of its fibres springing from the in- 
ferior border of the cartilaginous hook. The muscle then 
passes downward in front of the membranous portion of the 
canal, converging into a tendon which winds around the 
hamular process of the sphenoid and expands into a broad 
aponeurosis which is inserted into the anterior surface of the 
soft palate and into the posterior bony margin of the hard 
palate, the fibres uniting with those of the opposite side in 
the median raphe. 

The levator palati springs from the quadrilateral surface 
on the inferior aspect of the petrous bone, near its apex, and 
passes downward, forward, and inward to its insertion on the 
posterior and superior surface of the soft palate. The body 
of the muscle lies along the inferior margin of the cartilagi- 
nous plate which forms the posterior wall of the tube, to 
which it is loosely attached. It is also in contact with the 
fibrous inferior wall. 

A third muscle, sometimes included in this group, is the 
salpingo-pharyngeus, a muscular slip, which runs from the 
body of the palato-pharyngeus upward and forward to be 
inserted into the inferior wall of the tube. 

The Arteries (Plate III) of the conducting apparatus are 
derived chiefly from the external carotid artery, although a few 
branches spring from the internal carotid. The branches of 
the external carotid supplying the auricle, canal, and middle 



PLATE III. 




The Arterial Supply of the Conducting Apparatus. 



THE ARTERIES. 29 

ear are the posterior auricular, the superficial temporal, the 
occipital, the internal maxillary, and the ascending pharyn- 
geal. 

The posterior auricular is distributed to the posterior por- 
tion of the auricle and the corresponding part of the meatus. 
Through the stylomastoid branch which enters the stylo- 
mastoid foramen it supplies the mastoid cells, and sends a 
special branch to the stapedius muscle and to the stapes. It 
anastomoses with the superficial petrosal of the middle me- 
ningeal artery within the tympanic cavity, and with the tym- 
panic branch of the internal maxillary, forming with this lat- 
ter a complete vascular circle about the inner extremity of 
the meatus. 

The superficial temporal, through the superior and infe- 
rior anterior auricular arteries, supplies the anterior portion 
of the pinna and canal, the vessels anastomosing with the 
branches of the posterior auricular artery ; it also sends a 
small branch to the tympanum through the Glaserian fissure. 

The occipital artery sends branches to the concha, the ves- 
sels entering upon its cranial surface. 

The internal maxillary, through the middle meningeal and 
tympanic branches, is the most important source of blood 
supply, especially in early life. Before entering the cranium 
it sends a few twigs to the Eustachian tube. Within the 
skull it gives off the superficial petrosal, which enters the 
tympanum through the petro-squamous suture, and is dis- 
tributed to the roof of the middle ear, to the malleus and 
incus, and to a portion of the internal tympanic wall, where 
it anastomoses with the labyrinthine vessels, according to 
Politzer.* Within the Fallopian canal it communicates with 
the stylomastoid branch of the posterior auricular. 

The tympanic branch of the internal maxillary enters the 
middle ear through the Glaserian fissure, supplying the ante- 
rior portion of the cavity, and anastomoses with the stvlo- 
mastoid branch of the posterior auricular upon the periph- 
ery of the tympanic membrane. In early life this artery is 
much larger than the stylomastoid, and the vascular circle 
about the margin of the membrane from which the numerous 
vessels pass outward to the posterior wall of the meatus 
seems to spring from the tympanic branch of the internal 

* Archiv fur Ohrenheilk., vol. xi, p. 237. 



30 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



maxillary ; hence this artery is sometimes called the auricu- 
laris profunda. 

On the internal wall of the middle ear the tympanic artery 
anastomoses with the tympanic branches of the internal carotid 
and with the Vidian branch of the internal maxillary. In ad- 
dition to the two branches of the internal maxillary named 
above, the Vidian, the descending palatine, and the pterygo- 
palatine arteries, all springing from this trunk, send small 
vessels to the Eustachian tube and to the tubal muscles ; the 
descending palatine anastomoses freely with the ascending 
palatine branch of the facial and with the ascending pharyn- 
geal branch of the external carotid artery. 

In its passage through the carotid canal the internal carotid 
sends branches to the tympanum, which anastomose with the 
tympanic and Vidian branches of the internal maxillary. 

The Veins (Plate IV). — The veins are rather irregular in 
their distribution, but in general follow the course of the arter- 
ies. Most of the vessels from the deeper regions form a plexus 
upon the superior and supero-posterior walls of the external 
auditory meatus ; as they approach the orifice of the meatus 
the various venous channels anastomose freely with one an- 
other. Those on the posterior aspect of the canal and auricle 
pass into the external jugular and mastoid veins, while the an- 
terior branches go to join the temporal and facial veins. Some 
of the deeper vessels pass into the pterygoid plexus. The 
veins of the Eustachian tube follow the course of the arteries 
distributed to this region, and empty into the internal jugular 
directly, or occasionally communicate with the facial, the 
lingual, or the superior thyroid veins. Between the internal 
pterygoid muscle and the adjacent wall of the tube a trunk of 
considerable size establishes communication with the cavern- 
ous sinus ; near the pharyngeal orifice of the Eustachian ca- 
nal there is, according to Zuckerkandl,* a venous plexus com- 
municating with the turbinated bodies in the nasal cavities. 
The free anastomosis of the veins which return the blood 
from the deeper portions of the conducting mechanism is of 
particular importance from a therapeutic point of view, since 
this intercommunication between the various channels is 
comparatively superficial, and enables us to relieve deep- 
seated congestion by phlebotomy. The combined area of 

* Op. cit., p. 38. 



PLATE IV. 




The Venous Supply of the C 



Conducting Apparatu 



PLATE V. 




The Vascular Supply of the Cochlea. (Modified from Hyrtl.) 



THE LYMPHATICS AND NERVES. 3 1 

the veins is much greater than that of the arteries — a fact 
which in itself tends to cause the spontaneous resolution of 
any inflammatory process which may arise. Within the tym- 
panum the circulatory arrangement is somewhat unique, the 
capillaries being very short, or entirely wanting, and the 
arterial blood passes directly into the veins without the inter- 
position of the capillary system, as demonstrated by Prussak.* 

The Lymphatics. — The lymphatic channels are freely dis- 
tributed and anastomose both with the superficial lymph glands 
and with those forming the submucous lymphatic system of 
the pharynx. The superficial lymphatics over the mastoid, 
the lymph nodules in front of the auricle, and those situated 
in the cervical region between the platysma and the sterno- 
mastoid muscles are all intimately associated with the lym- 
phatic channels of the meatus and tympanum, while free 
lymphatic anastomosis exists in the opposite direction through 
the medium of the glands situated in the lateral pharyngeal 
walls. The lymph channels of the membrana tympani itself 
are arranged in three systems, one for each layer. These 
communicate freely with each other and with the lymphatic 
network of the external meatus. 

The Nerves (Figs. 20 and 21). — The muscles of the con- 
ducting apparatus derive their innervation from the trigem- 
inus, the facial, and the cervical plexus. The cervical plexus, 
through the occipitalis minor, supplies the attollens aurem ; 
the trigeminus, through the otic ganglion, supplies the tensor 
tympani and the tensor palati muscles ; the facial supplies 
the other muscles, either directly or through its ganglionic 
communications. 

The sensory nerves are derived from the cervical plexus, 
trigeminus, pneumogastric, and the glosso-pharyngeal trunks. 
The auricnlo-temporal, a branch of the trigeminus, supplies 
the auricle, the upper part of the meatus, and the membrana 
tympani. The auricnlaris magnns, from the cervical plexus, 
is distributed principally to the posterior part of the auricle 
and meatus, anastomosing with the auricular branch of the 
pneumogastric upon the posterior wall of the canal. 

The auricular branch of the vagus supplies the cartilagi- 
nous canal and a portion of the posterior surface of the auricle. 
The tympanic branch of the glossopharyngeal enters the mid- 

* Archiv fur Ohrenheilk., vol. iv, p. 290. 



32 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



die ear through a foramen in the floor of the cavity, and 
is distributed to its lining membrane and to the Eustachian 
tube. Upon the internal tympanic wall it divides. One 
branch anastomoses with the fibres of the carotid plexus from 
the sympathetic system, forming the tympanic plexus ; an- 
other nerve twig, the small deep petrosal, passes through a 
bony foramen in the tegmen tympani to the small superficial 
petrosal nerve, which is the facial tributary to the otic ganglion ; 
a third emerges from the cavity to join the great superficial 
petrosal, which is the facial root of the Vidian nerve, the pos- 
terior branch of Meckel's ganglion. This branch is called 
the great deep petrosal. 

Briefly, we may describe this complex nervous anastomo- 
sis as follows : The glossopharyngeal, through its tympanic 




Fig. 20. — The nerves of the conducting mechanism, and their anastomotic branches. 

branch, anastomoses with branches from the carotid plexus, 
upon the internal wall of the middle ear, forming the tym- 
panic plexus; from this plexus two branches are given off, 
one communicating with the otic ganglion, the other with 
Meckel's ganglion. 

We have yet to mention the chorda tympani, which, emerg- 
ing from the aquseductus Fallopii above the pyramid, crosses 
the tympanic cavity from behind forward, passing between the 
long process of the incus and the manubrium of the malleus. 
It leaves the middle ear through a separate canal which lies 



THE RECEPTIVE MECHANISM. 33 

close to the Glaserian fissure, and joins the lingual branch of 
the trigeminus. 

It can not but be noticed how richly the conducting ap- 
paratus of the ear is supplied with nerves, especially in the 
deeper and more delicate parts. More will be said upon this 
subject in considering the physiology of the conducting mech- 




FlG. 21. — The nerve distribution within the tympanum. 

anism, but the free anastomosis between the various nerves 
should be particularly borne in mind, for it is due to this fact 
that changes within the external or middle ear or Eustachian 
tube may give rise to remote symptoms, and that these re- 
gions may themselves be the seat of reflex disturbances. 

II. The Receptive Mechanism. 

We have now described that part of the apparatus of 
audition, concerned in the transmission of sonorous vibrations 
from without, to the point where they are brought into im- 
mediate relation with the end organ of the auditory nerve. 
Let us next consider the structures concerned in the inter- 
pretation of these sonorous vibrations. 

For reasons already given, we include under this general 
term, not only the internal ear, but also the auditorv nerve 
and its centers of origin, as well as the various avenues of 
communication with other centers, and with the correspond- 
ing nuclei of the opposite side and with the cortical area of 
audition in the brain. 
4 



34 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



For convenience of description, the course of the auditory 
nerve will be followed from the specialized end organ found 
in the labyrinth, inward toward its origin, rather than in the 
opposite direction, which would be more strictly correct from 
an anatomical point of view. 

The internal ear comprises the osseous and membra- 
nous labyrinth, the former being a series of communicating 
chambers tunneled in the petrous portion of the temporal 
bone and filled with fluid, in which the membranous labyrinth 
is suspended. This latter structure consists of a series of 
membranous tubes, also filled with fluid, called the endolymph. 
They follow the general contour of the osseous passages in 
which they lie, but do not completely fill them, the interven- 
ing space being occupied by the perilymph. 

The Bony Labyrinth (Fig. 22). — The bony labyrinth may 
be described as a central chamber in the petrous portion of 




Fig. 22. — The bony labyrinth. (Riidinger, Blake's translation.) I, Round window; 
2, Lamina spiralis ossea ; 3, Osseous cochlear canal ; 4, Floor of internal audi- 
tory meatus ; 5, Vestibule ; 6, 7, 8, 9, Semicircular canals. 

the temporal bone, called the vestibule, from which various 
tortuous channels diverge. This central chamber is ovoid in 
shape, the vertical diameter being the greater and measur- 
ing about one fourth of an inch, while the short diameter is 



THE BONY LABYRINTH. 35 

about one fifth of an inch. On its outer wall it presents a 
kidney-shaped opening, which under normal conditions is 
closed by the foot plate of the stapes. The inner w'all ex- 
hibits two fossae, separated by a bony spine called the crista 
vestibuli. The anterior depression, which is occupied by the 
saccule, is the recessus sphericus ; the posterior, lodging the 
utricle, is the recessus ellipticus. The posterior wall presents 
the openings of the three semicircular canals ; these openings 
are five in number, two canals, the superior and posterior 
entering the vestibule by a common channel. The entrance 
to the cochlear canal takes the place of the anterior wall of the 
vestibule. On the inferior internal wall, close to the border 
of the recessus ellipticus, there is a small opening, the orifice 
of the aquseductus vestibuli. Through this channel the cav- 
ities of the membranous labyrinth communicate with the 
subdural space. 

The semicircular canals are three in number, and are so 
disposed that the plane of each canal is perpendicular to 
that of the other two ; they are denominated the superior, 
posterior, and external canals. The posterior lies in the ver- 
tical plane of the long axis of the petrous portion of the 
temporal bone. The superior is placed at right angles 
to this, and is also vertical, while the external canal lies in 
the horizontal plane. As the name implies, each of these bony 
passages bends upon itself to form a semicircle, the point of 
origin and termination being the vestibule. The superior 
and posterior canals terminate in this cavity by a common 
opening, but with this exception each communicates with the 
vestibule by two openings, one of which may be considered 
the source and the other the terminus. Where the outer ex- 
tremity of the external canal enters the vestibule the lumen 
of the passage becomes dilated, forming what is known as an 
ampulla. The unjoined vestibular extremities of the posterior 
and superior canals are also ampullated. 

The Cochlea. — The entrance of this passage lies at the 
anterior and inferior aspect of the vestibule. It consists of a 
bony tube coiled two and a half times about an osseous axis 
— the modiolus. From the modiolus a thin septum of bone 
— the lamina spiralis — made up of two thin bony plates, ex- 
tends into the lumen of the tube, partially dividing it into 
two channels. This bonv partition does not extend com- 
pletely across the canal to the outer wall, the intervening 



36 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

space being bridged by a membranous septum, which com- 
pletes the division of the cochlear tube. This fibrous septum 
is called the lamina spiralis membranacea. The lamina spi- 
ralis at its free border divides into a superior and inferior 
limbus. The space inclosed by this separation is called the 
sulcus laminae spiralis. At the apex of the cochlea the par- 
tition which divides the canal into two distinct channels is 
incomplete ; the termination of the septum is somewhat 
hook-shaped, forming the hamular process, while the passage 
of communication between the superior and inferior spaces 
is called the helicotrema. The terminal half-turn of the coch- 
lea forms the cupola, and in this region the lamina spiralis 
ossea, just before its termination, is twisted upon itself in 
such a manner as to inclose a funnel-shaped space called 
the infundibulum. 

The modiolus is traversed by numerous canals, the larg- 
est running through its axis and named the canalis cen- 
tralis modioli, from which secondary channels diverge into 
the lamina. At the junction of the modiolus with the lamina 
a canal ascends spirally between the layers of this bony sep- 
tum, passing to the very apex of the cochlea. This is 
called the canalis spiralis modioli. The lamina spiralis ossea, 
with the membranous lamina, divides the bony cochlea into 
two passages, as already stated. The lower is called the 
scala tympani, the upper the scala vestibuli. The modiolus 
and the lamina are so disposed that the scala tympani does 
not communicate with the vestibule, but leads into the tym- 
panic cavity at the round window. In fact, we may consider 
the cochlear canal as beginning at the fenestra rotunda, at the 
inferior external angle of the vestibule, the wall at this point 
forming the modiolus. As the first turn passes forward and 
then upward from the round window, the contiguous walls of 
the tube and of the vestibule amalgamate and form a partition 
extending into the tube, which divides it into two channels, 
the upper of which communicates with the vestibule. The 
bony partition thus formed does not extend entirely across 
the tube, and the septum is completed by the membranous 
spiral lamina. Just beyond the round window in the floor of 
the scala tympani a narrow canal extends to the inferior sur- 
face of the petrous bone. This is the aquaeductus cochleae, and 
can be traced to the subarachnoid lymph space ; it affords an 
avenue of communication between the perilymph and the 



THE MEMBRANOUS LABYRINTH. 37 

intracranial lymph sac. After the lamina spiralis ossea sepa- 
rates into two thin plates of bone, each is continued as a 
membranous septum as far as the outer wall of the cochlea. 
Here, by their divergence, they inclose a triangular space, 
which extends from the round window to the apex of the 
cochlea, in a spiral direction ; this space, converted into a tube 
by the outer wall of the cochlea, is called the cochlear canal 
or scala media. Where the diverging septa join the outer 
bony wall of the cochlea the periosteum is thickened and 
richly supplied with blood vessels, especially where it joins 
the lower lamella, where it is called the ligamentum spirale. 

That portion of the membranous septum which is con- 
tinuous with the inferior lamella of the osseous spiral lamina 
passes outward in the same plane as the lamina spiralis ossea, 
and becomes the membrana basilaris. The upper leaflet 
forms an acute angle with this, and is called the membrane of 
Reissner. 

The manner of formation and the course of the various 
channels having been described, we have next to consider 
the lining membrane. 

The walls of the osseous canals and vestibule are covered 
by delicate fibrillated connective tissue rich in nuclear ele- 
ments ; this is applied closely to the osseous walls, constituting 
the periosteum. Its surface is covered with flat endothelial 
cells. The lumen of the bony semicircular canals or peri- 
lymphatic space is traversed by delicate bands of the con- 
nective-tissue covering of the osseous walls, which pass to the 
outer wall of the membranous canals, thus dividing the peri- 
lymphatic space irregularly. At the point of attachment of 
the membranous canals to the walls of the passage their lin- 
ing membrane is thickened. 

The Membranous Labyrinth (Fig. 23). — The membranous 
labyrinth consists of a series of tubes, formed of delicate con- 
nective tissue, lying within the bony channels already de- 
scribed. The membranous simicircular canals terminate in the 
utricle, which lies in the recessus ellipticus vestibuli, while the 
membranous cochlea is joined to the saccule bv a very narrow 
canal, called the canalis reuniens Hensenii. This entire series 
of tubes is filled with a clear fluid known as the endolvmph. 
Thus far we have described two series of channels, contain- 
ing fluid, terminating in somewhat spherical chambers — the 
utricle and saccule. The membranous cochlea terminates in 



38 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

a blind pouch (the lagena) at the apex of the bony passage 
in which it lies. From the adjacent aspects of the utricle and 
saccule a delicate canal is given off which coalesces into a 
common channel — the ductus endolymphaticus. This trav- 
erses the aquaeductus vestibuli and terminates in a blind sac 
(the recessus of Cutogno) upon the posterior surface of the 
petrous bone beneath the dura. According to Rudinger,* 
the endolymph may pass to the dural lymph spaces through 
this canal. The saccule and utricle lie upon the internal wall 




FlG. 23. — Adult membranous labyrinth (osmic-acicl preparation). (Retzius.) /, La- 
gena ; lis, Spiral ligament ; mb, Basilar membrane ; sv, Stria vascularis ; nits, 
Membrana tympani secundaria ; esc, Canalis reuniens ; s, Lower end of saccule ; 
cus, Canalis utriculo-saccularis ; de, Ductus endolymphaticus ; sp, Posterior utricu- 
lar sinus ; rec, Recessus utriculi ; aa, ae, ap, Ampullae of anterior, external, and 
posterior canals; vb, Vestibular cul-de-sac; ca, cc, cp, Semicircular canals; ss, 
Union of posterior and superior canals ; rb, rap, rs, ru, raa, rac, Branches of 
auditory nerve to various portions of membranous labyrinth ; ms, Macula acus- 
tica of saccule ; f, Facial nerve. 

of the bony vestibule, but do not fill the cavity completely, 
considerable space being left between them and the outer 
wall. The intervening space is filled with perilymph, and is 
called the cisterna lymphatica. It is of practical importance 
to remember that the distance from the inner surface of the 
foot plate of the stapes to the opposite wall of the membra- 
nous labyrinth is about three millimetres, or one eighth of an 
inch. In the same manner the lumen of the bony cochlea 



* Arch, fiir Ohrenheilk., vol. xxvii, p. 222. 



THE SACCULE AND UTRICLE. 39 

and semicircular canals is not completely filled by the con- 
tained membranous structures ; these latter are attached to 
the bony walls along the line of their convexity, and the 
periosteum is thickened along this line. Additional support 
is afforded the semicircular canals by bands of connective 
tissue which pass from the outer wall of the membranous 
channel to the osseous walls. 

Regarding the microscopical structure of the membranous 
labyrinth, it may be described as made up of a framework of 
connective tissue, the outer surface being covered by a reflec- 
tion of the endothelial layer which lines the bony labyrinth. 
The lining of the irregular cavity is of much greater interest, 
since it constitutes the special end organ of the auditory 
nerve. 

The Saccule and Utricle. — Upon the internal surface of the 
saccule and utricle, in the region corresponding to their at- 
tachment to the bony vestibular wall, there is a mound or 
papilla which encroaches somewhat upon the lumen of the 
cavity. This papilla is called the macula acustica, and is 
formed by the aggregation of the cells which form the lining 
of the space, the epithelium changing from the polygonal 
pavement variety to the cuboidal, and then to the cylin- 
drical form as it approaches the region of the macula. The 
papilla itself is covered by a specialized epithelium, the cells 
appearing under two forms, either as ciliated or hair cells, or 
as supporting cells placed between those before named. The 
supporting cells have large nuclei, and are either cuboidal be- 
low near the base, sending a delicate process to the surface, 
or they are fusiform, the nucleus lying near the centre. They 
terminate in elongated processes, one of which lies upon the 
surface of the papilla, the other passing to the basement 
membrane. 

The hair cells are elongated protoplasmic masses, each 
with an ovoid base, from which the body gradually tapers to 
a constricted portion called the neck, just below the superior 
extremity ; above this, the cell again becomes broad. From 
the free extremity of each cell, ten to twelve cilia? project 
into the cavity ; these are called the auditory hairs. Ac- 
cording to Kaiser,* whose description I have most closely 
followed here, the bodv of each hair cell is completely sur- 

* Arch, fur Ohrenheilk., vol. xxxii, p. 1S1. 



4 o THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

rounded by a delicate envelope, formed by the expansion of the 
axis cylinder of a single nerve fibrilla, although the axis cylinder 
cannot be traced with certainty into the cell body. The sur- 
face of the macula acustica constitutes the membrana limitans; 
this is reticular in structure, and through its spaces the audi- 
tory hairs project. In hardened specimens the auditory hairs 
are usually matted together, and the macula appears to be cov- 
ered by a finely fibrillated gelatinous substance, in which some 
of the ciliary processes can be made out. Lying between the 
ciliae, upon the surface of the macula we find an aggregation 
of minute crystals — the otoliths — apparently imbedded in the 
structureless covering of the mound. The agglutination of the 
auditory hairs is probably due to changes effected in the en- 
dolymph by fluids used in hardening the specimens. The 
macula acustica of the utricle and saccule are identical in 
structure. In the ampullae similar papillae are found, and are 
here called the cristas acusticae. The cristas acusticas are 
smaller than the maculae acusticae, their hair cells are also 
less developed, and the individual ciliae can not be made out. 
In hardened specimens the apex of the crista has the same 
structureless appearance as that of the macula, the homo- 
geneous substance surmounting it being here called the cu- 
pula. The appearance is probably due to the action of the 
hardening fluids upon the endolymph. The membranous 
canals are lined with polygonal pavement epithelium, and 
present, at various portions of their course, a papillary struc- 
ture. No nerve elements have been traced to the interior of 
the canals. 

The Membranous Cochlea or Scala Media. — This passage is 
joined to the saccule by the canalis reuniens Hensenii, and 
consists of a membranous tube, triangular on cross section, 
inclosed between the membrane of Reissner above, and the 
membrana basilaris below. Its outer wall is formed by the 
endothelial lining of the bony cochlea. At its lower extremity 
the canal terminates in a blind pouch at the round window, 
the caecum vestibuli, the basilar membrane completely shut- 
ting it off from the vestibule. The superior blind extremity is 
called the lagena. The superior and inferior walls are formed 
by a continuation of the divergent lips of the osseous spiral 
lamina, each of which becomes membranous after the division 
of the bony partition into two plates, and extends to the op- 
posite bony wall of the cochlea. The inferior membranous 



THE MEMBRANOUS COCHLEA. 41 

wall or floor is called the membrana basilaris. At the sulcus 
spiralis, the basilar membrane becomes much thickened, form- 
ing the limbus laminae spiralis, or crista spiralis. This separates 
into two lips, the furrow thus formed being called the sulcus 
spiralis internus. This groove is lined with cuboidal epithe- 
lial cells which pass upward to the vestibular lip. The basilar 
membrane stretches from the tympanic lip of the crista spira- 
lis to the spiral ligament ; it is made up of tightly stretched 
transverse fibres, the length of the successive fibres increas- 
ing from the base of the cochlea to the apex. The tympanic 
surface of the membrana basilaris is covered with polygonal 
pavement epithelium continuous with the lining of the scala 
tympani. 

The epithelium of the upper surface of the basilar mem- 
brane is cuboidal for a short distance beyond the sulcus spi- 
ralis internus ; the cells then become successively columnar, 
and farther outward undergo certain changes (to be de- 
scribed later), as a result of which there appears to be a ridge 
along the surface of the basilar membrane. Closer inspection 
shows that this ridge is really a series of arches. Beyond 
this ridge the cells again become cuboidal. This longitudi- 
nal ridge, which is continuous along the central portion of the 
basilar membrane from the round window to the lagena, ap- 
pears as a papilla in a vertical section of the cochlea, and is 
called the papilla acustica or zona tecta of the membrane ; 
the outer portion is called the zona pectinata, and the inner 
the zona perforata. The epithelium of the zona perforata is 
cuboidal and pierced with nerve fibres which reach it by 
passing outward from between the lips of the osseous lamina. 
Where it joins the zona tecta the cells become columnar, and 
are called the inner supporting cells. Next to these is a sin- 
gle row of elongated cells terminating above in ciliae ; these 
are the inner hair-cells. Beyond the inner hair-cells lie the 
inner rods of Corti, which rise from the basilar membrane, 
and form, with the outer rods, an arch called Corti's arch. 

This arch can be plainly seen in microscopic specimens i^see 
Fig. 24) when the sections are made perpendicular to the basi- 
lar membrane, since it extends throughout the entire length of 
the cochlea. These successive arches form a closed passage 
or tunnel from the lowest portion of the cochlea to its apex. 
covering over the portion of the membrana basilaris between 
the bases of the inner and outer rods. The inner rods arise 



4- 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



from a broad base and extend upward and outward at an 
angle of about sixty degrees. Immediately above the base 
the cells become narrow, transparent, and structureless : thev 
terminate in a club-shaped upper extremity or head, which is 
hollowed out on its outer aspect for the reception of a corre- 
sponding rounded process upon the outer rods. From the 
head of each inner rod a process extends horizontally inward, 
separating the adjacent hair cells. The outer rods are more 
numerous than the inner, and make an angle of about forty- 
five degrees with the basilar membrane; they are longer than 
the inner rods, but of the same shape, and their club-shaped 
heads fit into the articular process upon the outer surface of 
the head of the corresponding inner rod. The outer cells 
being greater in number than the inner, each member of the 



~r<' m fs dx 




Fig. 24. — Vertical section of the membranous cochlea. (Re:ziu;. | ■::, Limbus laminae 
spiralis ; mc, Membrane of Corti ; si, Sulcus internus ; is, Inner supporting 
cells ; ic, Inner rods ; in, Inner hair-cells ; dfr—d/r, Outer hair-cells ; dz, Dei- 
:ers's cells ; as, Supporting cells of Hensen ; rb, Nerve fibres ; n l -u*, rf, Nerve 
fibres to hair-cells ; at, Nuel's space ; vib, mb x , tb, Basilar membrane ; lis, Spiral 
ligament. 

latter series supports two or three of the external fibres of 
Corti. Bevond the outer rods there are found from three 
to five rows of hair-cells, of the same general structure as 
those observed in the zona perforata. Thev rise, however, 
almost perpendicularly from the basilar membrane, thus leav- 
ing a space between the outer rods and the inner row of hair 
cells, known as Xuel's space. The rows of outer hair-cells 
are separated from each other by the cells of Deiters. These 
are broad at their base, but narrow as thev approach the sur- 
face, and are marked along their inner border by a bright 
line which runs the entire length of the cell from the upper 
to the lower extremity. The upper extremity of this bright 
line, called the supporting fibre, terminates in a delicate 
lamella or phalanx: the contiguous phalanges form by their 



THE MEMBRANE OF CORTI. 43 

union a reticular membrane, through the interstices of which 
the outer hair-cells project. Beyond the cells of Deiters the 
epithelium again becomes columnar, forming the outer sup- 
porting cells, beyond which it resumes gradually the form 
found in the zona pectinata. 

The membrana reticularis is formed by the union of the 
phalanges of the supporting fibres of Deiters's cells ; its outer 
limit is poorly defined. It passes inward from the inner row 
of Deiters's cells to the summit of Corti's arch, to which it is 
attached. 

The Me7nbrane of Corti, or Membrana Tectoria. — This is 
a gelatinous membrane arising from the upper border of the 
sulcus spiralis internus, just below the attachment of Reissner's 
membrane, and extending outward, over the papilla acustica, 
beyond the outer row of Deiters's cells ; it is intimately con- 
nected with the hair-cells, but in exactly what manner is still 
a mooted question. The hair cells are supposed to be the 
specialized end organ of the cochlear nerve ; the nerve fibres 
pass through the zona perforata as naked axis cylinders, and 
have been traced by Katz * to the interior of the inner hair 
cells. Delicate fibrillar also cross beneath the arch of Corti, 
and have been traced to the outer of Deiters's cells and to 
the outer hair cells which they probably enter, although this 
is not certain. 

Having described the peripheral termination of the au- 
ditory nerve, we will next follow its fibres backward to the 
main trunk. 

From the cochlear hair-cells the filaments pass inward be- 
tween the layers of the osseous spiral lamina, resume their me- 
dullated layer, and unite to form the cochlear branch of the 
auditory nerve in the tubulus centralis modioli. Where the 
fibres of distribution radiate from the central trunk within the 
modiolus a ganglionic enlargement is found, called the spiral 
ganglion. From the cristae acusticae and maculae acustica? 
the nerve filaments pass through minute foramina in the walls 
of the bony labyrinth. The nerve filaments unite to form the 
vestibular branches of the auditory nerve, the fibres from the 
saccule forming the inner branch, those from the utricle and 
ampulla of the external and superior canals the superior 
branch, and those from the ampulla of the posterior canal the 

* Arch, fur Ohrenheilk, vol. xxix, p, 54. 



44 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

inferior branch. These foramina constitute the macula cri- 
brosa of the fovea spherica, and fovea elliptica. 

The Blood Supply of the Labyrinth (Plate Y).— The 
Arteries. — The blood supply is derived from the internal audi- 
tory artery, a branch of the basilar. The artery accompanies 
the auditory nerve to the labyrinth, where it divides into two 
branches, the one supplying the vestibule and semicircular 
canals, the other following the cochlear branch of the nerve to 
the cochlea, where minute vessels pass outward, forming an 
arterial plexus for the supply of the membranous cochlea. The 
minute vessels radiate from the larger arterial twigs toward 
the outer labyrinthine walls of the scala vestibuli and scala ty m- 
pani, but are most prominent in the walls of the scala vestibuli. 

The Veins. — The veins follow the same general course as 
the arteries, the smaller branches uniting to form three main 
channels — the vein of the cochlear aqueduct, the vein of the 
aquasductus vestibuli, and occasionally a third vessel is found, 
the internal auditory vein, although this is the least constant 
branch. 

The vein of the aquasductus cochleae passes through the 
cochlear aqueduct to the internal jugular. The vestibular vein 
joins the superior petrosal sinus, leaving the labyrinth through 
the aquasductus vestibuli, while the internal auditory vein ac- 
companies the artery of the same name and empties into either 
the transverse or inferior petrosal sinus. 

The terminal branches of the venous channels anastomose 
freely with one another, forming spiral plexuses or loops. In 
general, it may be said that the blood current enters the laby- 
rinth upon one aspect, and, instead of forming a complete cir- 
cuit and finding an exit in the same region, passes out on the 
opposite side of the labyrinthine cavity, the chief avenue of 
venous discharge from the cochlea being the vein of the coch- 
lear aqueduct. 

Boettecher* describes a capillary twig running along the 
tympanic surface of the basilar membrane under the arch of 
Corti, which he calls the vas spirale of the cochlea. Its exist- 
ence has been denied by Berthold,fand Siebenmann4 Eichler* 

* Arch, fur Ohrenheilk, vol. xxiv, p. i. 

f Schwartze's Handb. der Ohrenheilk., 1893, vol. i, p. 711. 
% Arch, fur Ohrenheilk., vol. xxxv, p. 115. 

* Abhandl. d. math. phys. Klasse der k. sach. Gesell. der Wissenscnaft des physi- 
olog. Inst, zu Leipzig, 1892, vol. xviii, No. 5, p. 311. 



PLATE V 




The Auditory Nerve. (Modified from Freud.) 



THE AUDITORY NERVE. 45 

has made important investigations upon this subject, from 
which it seems probable that the capillary spiral plexus is 
formed by the cochlear vessels both in the sulcus internus 
and upon the tympanic surface of the basilar membrane be- 
neath the arch of Corti. The spiral plexus is particularly 
prominent in the lower turn of the cochlea. A somewhat 
similar anastomosis exists also in the ligamentum spirale. 

According to Siebenmann's investigations, the internal au- 
ditory artery usually divides into three branches — the coch- 
lear, vestibular, and vestibulo-cochlear — the particular por- 
tions supplied by each branch being sufficiently indicated by 
their respective names. The particular manner in which the 
trunk divides is of but small practical importance, but we 
should remember that the blood supply of the lower turn of 
the cochlea is much more abundant than that of the upper 
portions of the spiral. 

If a vertical section is made through the cochlea, it will be 
found that the arterial trunks lie chiefly in the walls of the 
scala vestibuli, as already mentioned, while the venous chan- 
nels are mostly confined to the walls of the scala tympani. 
This arrangement is shown diagrammatically in Plate III, 
from which it will be seen that the arterial capillaries pass 
into the venous in the region of the ligamentum spirale. 

The Auditory Nerve (Plate VI). — The auditory nerve 
trunk constitutes the portio mollis of the older anatomists, 
and is given off from the medulla at the posterior border of 
the pons Varolii. It arises from two roots, the lateral or an- 
terior, constituting the vestibular nerve, while the internal or 
posterior fibres form the cochlear portion. 

The Cochlear Nerve. — The posterior root, called also the in- 
ternal, constituting the cochlear nerve, arises from a large- 
celled nuclear mass in the medulla (the anterior or ventral nu- 
cleus) and from a smaller aggregation of cells lying to the 
outer side of this, the tuberculum acusticum. From the ven- 
tral nucleus of each side two bundles of fibres are given off, 
one of which is of large size and passes to the olivary bodv of 
the opposite side, the other, of smaller dimensions, to the olivary 
body of the same side. The crossed fibres bv their decussa- 
tion constitute the corpora trapezoides, a name applied on ac- 
count of the peculiar appearance which thev give to a section 
of the medulla in this region. From each olive four sets of 
fibres are given off. The larger number pass to the posterior of 



46 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

the corpora quadrigemina through the fillet, a small bundle 
passes to the spinal cord, a third passes to the region of the 
abducens nucleus and communicates with it, while a fourth 
bundle of fibres passes to the cerebrum. From the tubercu- 
lum acusticum a small bundle of fibres crosses the median 
line to the opposite fillet, uniting with those which pass be- 
tween the olivary body and the posterior of the corpora quad- 
rigemina of this side. 

To recapitulate briefly, most of the fibres from either 
cochlear nerve pass to the opposite side of the brain through 
the trapezoid bodies to the opposite olive, then through the 
fillet to the posterior quadrigeminal body, accompanied by a 
few filaments from the tuberculum acusticum. A small pro- 
portion of the fibres in the cochlear nerve in question do not 
cross, but pass to the cortical centres of the corresponding 
side of the brain through the olive of this side. The course 
of the fibres from the corpora quadrigemina has not been defi- 
nitely made out, although the position of the nuclei in the 
medulla and the decussation of the fibres has been verified 
by physiological experiment. After entering the corpora 
quadrigemina the fibres are supposed to pass to the poste- 
rior third of the internal capsule, and from there to the first 
and second temporal convolutions, this being the auditory 
centre in the cortex according to the most recent investiga- 
tions. 

The Vestibular Nerve. — The vestibular nerve arises from 
the internal or dorsal nucleus, close to the vagus centre, but 
superficial to this. Branches originating in this collection of 
nerve cells cross the raphe, embracing in their course the 
nucleus of the sixth nerve and pass to the cerebral cortex, 
although the exact course which they follow is undetermined. 
A large fasciculus extends to the cerebellum, passing first 
through the pons, then the vermis, and finally terminates in 
the corresponding cerebellar hemisphere and in that of the 
opposite side. The dorsal nucleus communicates with the 
spinal cord through a fasciculus which passes downward and 
inward between the olivary bodies. 

Besides the cochlear and vestibular roots, the auditory 
trunk contains a bundle of fibres which emerge between the 
roots already described. These arise from an aggregation of 
cells, called Deiters's cells, lying in the medulla between the 
anterior nucleus and the olivary body. The branches of com- 



THE AUDITORY NERVE. 



47 



munication with the other nuclei of the eighth nerve and with 
other cerebral centres are undetermined. 

We thus appreciate the complexity of the central portion 
of the acoustic apparatus, and may realize what manifold 
causes may exist for impairment or perversion of function. 
We must bear in mind that any disturbance of audition of 
nervous origin may be variously located at any point between 
the cochlea, which represents the end organ of the auditory 
nerve, and the first and second temporal convolutions of the 
cerebrum, which represent the cortical auditory area. The 
fibres from the cochlea of either side, according to our descrip- 
tion, pass through the cochlear nerve to the ventral nucleus 
and to the tuberculum acusticum, most of the fibres passing 
to the superior olive of the opposite side through the corpora 
trapezoides, and then to the corresponding posterior quadri- 
geminal body through the fillet ; thence to the posterior third 
of the internal capsule, and tnence to the first and second 
temporal convolutions. A smaller collection of fibres from 
the anterior or ventral nucleus passes to the olive of the same 
side, through the trapezoid body and to the cortical area of 
this side, following a course similar to that pursued by the 
fibres from the opposite olivary body ; from this olivary 
body other fibres pass to the cerebellum, to the spinal cord r 
and to the abducens nucleus. 

The portion of the cochlear nerve terminating in the tuber- 
culum acusticum sends a few decussating fibres to the oppo- 
site fillet, its only other communication being that afforded 
by its immediate proximity to the anterior nucleus. 

The vestibular nerve twigs amalgamate into a trunk, which 
terminates in the internal or dorsal nucleus, from which fibres 
pass to the spinal cord, to the cerebellar hemisphere of the 
same, and to that of the opposite side, and probably to the 
opposite cerebral hemisphere. The communication with the 
cerebellum is the most extensive, and this portion of the brain 
constitutes the important terminus of the vestibular branch 
of the auditory trunk. 



CHAPTER II. 

THE PHYSIOLOGY OF THE EAR. 

In order to understand the manner by which sound per- 
ception is effected, it will be well to recall the physical prin- 
ciples involved in sound production and transmission. 

Sound is a mode of motion produced by the vibration of 
matter. Vibrations are transmitted to the organ of hearing 
through any elastic medium. If the vibrations succeed each 
other at regular intervals and with sufficient rapidity they 
affect the ear collectively, rather than as separate impulses, 
and produce what is known as a musical sound. If the im- 
pulses are irregularly repeated, or if the interval between 
each is of considerable duration, the impression constitutes 
a noise, each act of transmutation of energy into motion 
producing an effect upon the receptive centres. When the 
impulses follow each other at a rate of less than sixteen per 
second they are observed singly ; but if at a greater rapidity, 
the sound becomes musical and continuous. According as 
the rate of vibration is slow or rapid, the note is of low or 
high pitch, until finally the vibrations follow each other so 
rapidly that the ear no longer appreciates them. From this 
we see that the ear possesses certain limits of perception for 
musical sounds, between which all regularly recurring vibra- 
tions impress the organ in a certain definite way. These 
limits are called the tone limits of the ear, and range from 
about sixteen double vibrations per second to thirty-two thou- 
sand five hundred double vibrations per second. 

It will be understood that the figures given represent the 
average limits only, in certain instances the lower limit being 
somewhat below the one given, while the upper limit may be 
higher. Quite distinct from the pitch of a note is its intensity 
or loudness ; this depends upon the amplitude or extent of 
each individual vibration. Although depending upon entirely 
different physical conditions, pitch and intensity are, to a cer- 



SOUND. 



49 



tain extent, related, since, as the vibrations increase in num. 
ber, the space traversed during each unit of time by a vibrat- 
ing body must be less. We quite unconsciously prove the 
truth of this statement when we remember that we associate 
loud sounds with high, shrill notes, while the reverse is true 
of tones of the lower portion of the register. In other words 
a given force will produce a more intense sound if it acts upon 
a body in such a manner as to produce molecular vibrations 
rather than vibrations en masse. 

For convenience in recording the various rates of vibration, 
a tuning fork, or other sounding body making sixteen double 
vibrations per second (V. D.), may be called C- 2 ; one making 
double this number of vibrations would be called C- 1 ; the 
two notes differing from each other by an octave. This divi- 
sion of the musical scale, should be remembered as indicating 
that when two musical notes differ from each other by an 
octave the rates of vibration are as two to one. 

In the above we have considered simple vibrations only ; 
but it is to be remembered that a note is seldom heard ab- 
solutely pure, but is accompanied by tones of higher pitch in 
the musical scale. These are called overtones, and they modify 
the character of the fundamental note. These overtones give 
the individuality or quality to the various instruments used in 
an orchestra, and enable us to distinguish whether a given note 
is sounded upon a wind or string instrument. These har- 
monics are much more prominent in the lower divisions of 
the scale, and, as will be seen when we come to speak of the 
functional examination of the ear, are to be borne in mind, 
since by their perception, in place of the fundamental tone 
erroneous deductions may be drawn. 

Sound waves are propagated in any medium surrounding 
a vibrating body at rates varying with the density of the 
medium. The rate of transmission is greater in solids and 
liquids than in gases. In gaseous media the rate of trans- 
mission of sound is in inverse proportion to the densitv of 
the gas. 

We are now prepared to study the action of the transmit- 
ting mechanism of the ear from a physiological standpoint, 
bearing in mind that this portion of the organ subserves the 
purpose simply of conducting aerial vibrations to the end or- 
gan of the auditory nerve, which analyzes them, so that each 
individual note produces certain specific effects upon the re- 



5 o THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

ceptive centres. We next consider the use of the various 
portions of the conducting mechanism. 

The Auricle. — The auricle, representing the open end of a 
funnel, collects aerial vibrations and directs them into the ex- 
ternal meatus. Its angle of attachment to the skull and the 
variations in contour encountered in different individuals no 
doubt exert slight influences upon sound perception, but this 
fact may be practically disregarded in man, and the auricle 
may be removed without seriously interfering with the func- 
tion of audition. Among the lower animals the auricle plays 
a very important part in the sense of hearing, being movable, 
and capable of assuming various positions from volition or 
reflex action in order better to collect aerial vibrations from 
different points. 

The External Meatus. — The external meatus constitutes 
a tube through which the sonorous impulses are conveyed in- 
ward toward the labyrinth with undiminished intensity. Even 
if this tube is very small in its deep portion, the function of 
audition may be but little impaired, the oscillations in the 
column of air being transmitted with undiminished intensity. 
If the narrowing takes place at the orifice of the meatus, 
acuteness of hearing is much diminished. This condition is 
occasionally found in the aged in whom the tissues have un- 
dergone a certain amount of atrophy, resulting in the collapse 
of the superior wall of the cartilaginous meatus to such an ex- 
tent that it lies in contact with the inferior wall, completely 
occluding the canal. Occasionally the tragus is abnormally 
developed, and projects backward over the mouth of the 
canal in such a manner as to offer an obstruction to the en- 
trance of the sound waves. This condition also renders the 
hearing less acute. 

As mentioned in a previous chapter, the external auditory 
meatus is not directed horizontally inward, but the cartilagi- 
nous and osseous portions join at an obtuse angle both in 
the horizontal and vertical plane. The cartilaginous canal is 
directed upward, backward, and inward, while the osseous 
portion extends forward, downward, and inward. Where the 
cartilaginous meatus joins the auricle the posterior wall pre- 
sents a deep fossa or depression, and the antero-inferior wall 
of the bony canal close to the membrana tympani exhibits a 
somewhat similar feature. In the cartilaginous canal this 
excavated portion acts with the auricle to collect the waves 



FUNCTION OF THE MEMBRANA TYMPANI. 51 

of sound and direct them into the meatus, while by the hol- 
lowing out of the antero-inferior wall of the deeper portion of 
the meatus, the surface presented is parabolic, from which 
reflected waves are directed almost perpendicularly upon the 
drum membrane. Since the meatus is a closed tube it neces- 
sarily possesses a fundamental note, which, according to 
Gad,* lies in the fourth accentuated octave, representing 
about 4,056 V. S. The effect of the resonant action of the 
canal upon audition is practically inappreciable, its primary 
note lying beyond the limit of the conversational voice. When, 
however, the middle ear is filled with fluid or the drum mem- 
brane is much thickened, the resonant action of the canal 
becomes more marked and is demonstrable. This is also 
true when the meatus is closed with the finger or occluded 
by a foreign body, the imprisoned column of air under these 
conditions being set in vibration through the medium of the 
cranial bones. 

The Membrana Tympani. — This structure acts at once as 
a protective septum to the parts lying within the middle ear, 
and as a mechanical device for the reception of sonorous vi- 
brations, which are then transmitted through the agency of 
the ossicular chain to the perilymph, being brought into rela- 
tion with this fluid by the foot plate of the stapes. The ad- 
vantage gained depends upon the relatively large surface 
which the membrana tympani presents in comparison with 
that of the foot plate of the stapes. Any impluse, there- 
fore, acting upon the membrane is transmitted to the stapes, 
at which point its power is much augmented. The drum 
membrane is usually spoken of as a tense fibrous septum, and 
hence should possess a fundamental note peculiar to itself. 
The fact is, however, that, owing to the arrangement of the 
radiating and circular fibres of the lamina propria, its mode 
of attachment to the malleus handle, its oblique position, 
and the relaxed condition of its upper portion — the mem- 
brana flaccida — its fundamental note exercises but an un- 
important influence upon the sense of hearing. It therefore 
transmits notes, varying greatly in pitch, with equal facility 
and without the accentuation of any particular tone, a phe- 
nomenon which would necessarily occur if the membrane 
itself possessed a fundamental note. This impartial transmis- 

* Schwartze, Handb. cler Ohrenheilk., Leipzig, 1S92, vol. i, p. 33S. 



52 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

sion of sound waves which impinge upon it, without reference 
to their pitch depends chiefly upon the disposition of the cir- 
cular and radiating fibres in its connective-tissue layer. The 
circular fibres serve to obliterate any resonant action which 
might result from the radiating fibres being thrown into sym- 
pathetic vibration. In the same way the handle of the malleus 
aids in cutting off the overtones, acting as a load upon the vi- 
brating membrane .and preventing the accentuation of any 
harmonic. The umbilication of this diaphragm at the umbo 
possesses a mechanical advantage, a force acting upon it being 
increased in intensity as it is transmitted to the malleus handle, 
while the distance traversed by the manubrium is correspond- 
ingly diminished. 

The Ossicular Chain. — The alternate conditions of conden- 
sation and rarefaction brought about by a sounding body are 
transmitted to the labyrinthine structures, after impact against 
the drum membrane, through the ossicular chain. The outer 
member of this chain, the malleus, is attached to the membra- 
na in the manner already described, while the innermost os- 
sicle, the stapes, is in contact with the labyrinthine fluid at 
the oval window. Helmholtz * has shown, from the physical 
laws governing the transmission of sonorous vibrations, as 
the dimensions of the ossicles are so minute in comparison 
with the length of the waves which they transmit, that they 
may be considered as acting en masse — that is, each component 
of the chain acts as a single oscillating particle of infinitesimal 
dimensions, rather than as a solid body the molecules of which 
are in a state of vibration. Viewed in this manner, we have 
to deal with a system of levers through which a force applied 
at the tip of the malleus acts upon the stapes with increased 
energy, but with a corresponding diminution in the space 
traversed in a unit of time. As the result of experiment, the 
same author f found that any force acting upon the tip of the 
manubrium was augmented one and a half times at the incudo- 
stapedial articulation, the extent through which the tip of 
the long process of the incus moved being diminished two 
thirds. 

The preceding remarks regarding the lever-like action of 
the ossicles refers only to forces tending to displace the mal- 
leus inward. It will be remembered that in describing the 

* Op. cit., p. 12. f Op. cit., p. 46. 



THE FUNCTION OF THE OSSICLES. 53 

ligaments of the tympanum, it was stated that the anterior 
and posterior ligaments constituted the axis band of the mal- 
leus, this bone being supported at their points of insertion 
into its neck, and rotating about an imaginary line passing 
through these points and the tympanic attachments of the 
ligaments as an axis. The peculiar structure of the malleo- 
incudal articulation must also be borne in mind, the articular 
surface of the head of the malleus being in contact with the 
saddle-shaped articular surface of the incus. This articular 
surface is provided with a toothlike projection, so that when- 
ever the manubrium of the malleus moves inward, with a con- 
sequent outward movement of the head, this motion is trans- 
mitted to the incus, and by this ossicle conveyed to the stapes. 
If, however, the tip of the manubrium is drawn outward, the 
toothlike process of the incus no longer engages the mal- 
leus, and the articular surfaces of the ossicles become sepa- 
rated. From this it follows that the stapes is but slightly 
displaced outward under these conditions. The practical 
importance of this will be seen at once when we remember 
how frequently the tympanic cavity is suddenly filled with 
air, either by accident or design, causing an extensive out- 
ward displacement of the membrana tympani. If the articu- 
lar surfaces remained in contact under these conditions the 
effect would be to draw the stapes from the oval win- 
dow. The long arm of the lever above described extends 
from the tip of the manubrium to the short process of the 
incus, while the point of transmission of force to the stapes 
lies in this line at the tip of the long process of the incus. 
The relative lengths of these two arms is in proportion of three 
to two, and the mechanical advantage gained is in the same 
ratio. The movement of the stapes is not directly inward, 
but rather in an oblique plane, the ossicle being rotated about 
its lower and posterior border. Motion in this oblique plane 
results not only from the peculiar position of the oval win- 
dow, but also from the manner in which the incus is fixed to 
the tympanic wall, an inward excursion of the malleus carry- 
ing the long process upward and inward at the same time. 
The obliquity of the plane in which the ossicles are placed 
causes a slight movement forward in addition to the dis- 
placement described, the resultant motion imparted to the 
stapes being a rotation about its posterior and inferior bor- 
ders. The capsular ligament of the malleo-incudal articula- 



54 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

tion plays an important part in the proper performance of 
the function of this joint. If this ligament is relaxed, the 
articular surface of the malleus, instead of being held closely 
against the corresponding surface of the incus and engaging 
the tooth-shaped process of the articular facet, is drawn 
away from the saddle-shaped articular surface of the incus, 
and causes but slight movement of the ossicle. This condi- 
tion would interfere particularly with the transmission of 
those notes, the wave length of which was relatively con- 
siderable — in other words, the lower notes of the register. 
Too great tension of the capsular ligament interferes with 
free oscillation of the ossicular chain, and consequently with 
the proper transmission of sound waves, particularly those 
of low pitch. High notes, demanding but little displacement 
of the transmitting mechanism, are relatively less interfered 
with by anomalies in the tension of the tympanic ligaments. 

It is interesting to note here the experiments of Politzer* 
regarding the effect produced by notes of various pitch 
upon the excursions of the ossicular chain. It was demon- 
strated that the oscillations of the ossicles were less extensive 
for very low notes than for those of the middle portion of 
the scale. When the pitch was very high, however, the am- 
plitude of the ossicular vibrations was again diminished. The 
weighting of the ossicular chain interfered with the trans- 
mission of low-pitched sounds, while the higher ones were 
transmitted practically without interference. As stated 
above, although pitch depends upon the rate of vibration 
and intensity upon the extent of each oscillation, a certain 
relation must exist between them, as is proved by the well- 
known fact to which Gad f calls attention — that of two notes 
sounded with the same intensity, the higher will seem the 
louder. The importance of these circumstances can not be 
overestimated in their bearing upon pathological conditions 
of the conducting apparatus, since the result of clinical ob- 
servation agrees with that of physiological experiment, show- 
ing that in affections of the transmitting mechanism alone, 
the impairment of function occurs first for sounds of very 
low pitch, the upper notes being transmitted with a fair de- 
gree of accuracy. 



* Archiv fur Ohrenheilk., vol. vi, p. 35. 

f Schwartze, Handb. der Ohren., Leipzig, 1892, vol. i, p. 336. 



THE FUNCTION OF THE MUSCLES. 55 

The Tympanic Muscles. — We have considered above the 
part played by the ossicles alone, without regard to the ac- 
tion of any muscles which might modify their response to 
aerial vibrations. It is necessary, however, to bear in mind 
that, in addition to their ligamentous supports, their action 
is modified by two muscles — the tensor tympani and the 
stapedius. The anatomical characteristics of these have al- 
ready been described. 

The tensor tympani muscle, acting alone, would tend to 
draw the ossicles inward and upward, crowding their articu- 
lar surfaces together and forcing the foot plate of the stapes 
into the oval window. This displacement would of necessity 
render the membrana tympani more tense ; hence the name 
of the muscle, although its action in this direction is of but 
little practical importance. 

The action of the stapedius is antagonistic to that of the 
muscle just described, since by its contraction the stapes is 
drawn out of the oval window by rotating upon the posterior 
margin of the foot plate, with the effect of reducing the ten- 
sion of the labyrinthine fluid. It is probable that one of the 
chief uses of these muscles is to protect the labyrinth from 
the injurious effects of loud sounds, or of the sudden conden- 
sation of air in the meatus from any cause. Since they act in 
opposite directions, they increase the elasticity of the ossicu- 
lar chain, the one guarding the labyrinth from sudden pres- 
sure from without, while the other, by crowding the ossicula 
together, militates against any outward displacement of the 
ossicles from any increase in intratympanic pressure. One 
value of this action is to guard the capsular ligament of 
the malleo-incudal articulation, the fibres of which would 
soon become stretched by repeated condensations of air in 
the tympanic cavity if it were compelled to sustain the entire 
pressure. 

The Muscles of the Eustachian Tube. — In order that the 
membrana tympani may act simply as a transmitter and col- 
lector of aerial vibrations of various lengths, it is essential 
that its normal tension shall not be interfered with. An abso- 
lutely constant tension of this membrane can exist only when 
the atmospheric pressure is the same on either side. To pre- 
serve this equilibrium, the cavity of the tympanum, under nor- 
mal conditions communicates freely wfth the outer world 
through the Eustachian tube. Owing to the fact that the an- 



56 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

terior and inferior walls of the membranous portion of the 
passage are formed almost entirely of fibrous tissue, the an- 
teroposterior walls are in contact, except along the roof, where 
the patency is preserved by the hook-shaped process of the 
cartilaginous plate. Although the physical conditions admit 
of the canal remaining patent in this situation, it is probable 
that the mucous membrane lining the passage is so loosely ap- 
plied, that even here the lumen is practically obliterated 
when the parts are at rest, but that slight changes in pressure 
suffice to render the tube permeable in this portion. This is 
particularly- true if the intratympanic pressure is increased, 
as air passes more easily from the tympanum through the 
tube than in the opposite direction. It is comparatively un- 
important whether in certain cases the canal is patent while 
the parts are at rest. Since the aeration of the tympanum is 
accomplished through the action of its attached muscles, the 
part played by them in audition is one of great importance. 
It will be remembered that the tensor palati and the levator 
palati are in relation with the fibro-cartilaginous portion of the 
Eustachian passage, the former arising in part from its ante- 
rior wall, while the latter passes beneath the membranous floor 
along the inferior border of the posterior cartilaginous wall. 
Contraction of these muscles increases the caliber of the tube, 
the tensor drawing the anterior wall and the cartilaginous 
hook forward, while the belly of the levator is augmented in 
volume during contraction and presses the inferior and pos- 
terior walls upward, diminishing the diameter of the canal 
from above downward, but making it more patent. As both of 
these muscles are brought into play during the act of deglu- 
tition, the removal of the air within the middle ear must of 
necessity take place so frequently that the equilibrium of the 
membrana tympani is not disturbed. Temporary variations 
in pressure are undoubtedly compensated for by the action of 
the stapedius and tensor tvmpani muscles. When, owing to 
atrophy of the tubal muscles or to obstruction of the lumen of 
the canal from swelling of the lining membrane or from the 
presence of secretion, the passage remains closed for a con- 
siderable period, rarefaction of the air within the tympanum 
is the result. This is brought about bv the absorption of air 
into the blood circulating in the lining membrane of the mid- 
dle ear, and by the greater facility with which the air passes 
from the tympanum than in the opposite direction. This re- 



THE FUNCTION OF THE COCHLEA. 57 

duction in pressure within the middle ear allows the mem- 
brana tympani and attached ossicular chain to be forced in- 
ward by the pressure of the atmosphere, crowding the stapes 
into the oval window. 

The Labyrinth. — The physiology of the labyrinth divides 
itself into an investigation of the function of the vestibule, the 
cochlea and the semicircular canals. 

The Cochlea. — The cochlea is that part of the internal ear 
specialized for the analysis of sonorous vibrations. Through 
its agency each component of any complex sound affects one 
portion of the terminal fibres of the auditory nerve. These 
various stimuli are again combined in the higher nerve centres, 
and are interpreted as characteristic of some particular vibrat- 
ing body, and hence from education enable us to judge of the 
conditions under which they were produced. To effect this 
separation of the complex aerial vibrations the undulations are 
transmitted by the conducting mechanism to a column of fluid, 
the perilymph. Recollecting the anatomy of the parts, it will 
be remembered that the cochlear perilymphatic space is di- 
vided into two channels lying one above the other, communi- 
cating at the apex of the spiral by a narrow passage, the heli- 
cotrema, and separated from each other by a septum which is 
partially osseous and in part membranous. The membranous 
portion incloses between its two layers a channel, triangular 
on cross-section, the membranous cochlea. This canal is an 
elongated blind pouch, and is filled with endolymph in which 
float the ultimate fibres of the auditory nerve. 

The upper cochlear canal communicates with the vestibule, 
while the lower is shut off from the middle ear by the mem- 
brane of the round window. The membranous cochlea termi- 
nates at its superior extremity as a blind sac, while below it 
joins the saccule. The floor of this membranous tube begins 
at the upper part of the round window. The perilymphatic 
space through the aqueductus cochlea? communicates with 
the subarachnoid lymph space, while the endolymphatic chan- 
nel, through the aqueductus vestibuli, opens into a sac be- 
tween the layers of the dura mater. The probability of the 
communication between thisdural pouch and the lymph chan- 
nels of the dura has already been discussed. 

Aerial vibrations communicated to the stapes produce a fluid 
wave in the perilymph, each inward excursion of the ossicle 
pushing the column of fluid before it through the scala ves- 



58 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

tibuli, thence through the helicotrema, and finally through the 
scala tympani to the round window, the membrane of which 
is pushed outward into the tympanum to compensate for the 
inward motion at the vestibular opening. Since the labyrin- 
thine walls are rigid in every other situation, and from the 
well-known physical law that fluids are incompressible, this 
motion of the perilymph is impossible unless the membrane 
of the fenestra rotunda is elastic. The elastic partition sepa- 
rating these two channels modifies to an extent the course 
taken by this wave in the perilymphatic fluid. This septum, 
consisting of two layers, the space between being filled with 
fluid of the same density as the perilymph, permits of the 
transmission of the wave motion from the upper to the 
lower channel without necessitating its passage through the 
helicotrema. It is evident that the structures within the 
membranous cochlea must suffer some disturbance of equi- 
librium from the passage of this fluid wave. An impulse 
causing the inward motion of the stapes is communicated 
to the perilymph, which in turn exerts a pressure upon the 
basilar membrane ; this elastic septum yields to the pressure 
in localities varying according to the pitch (or rate of vibra- 
tion) of the particular note sounded. The depression of the 
basilar membrane at any given point causes a change in 
position in the structures resting upon it : these, it will be 
remembered, are the hair-cells and the rods of Corti. It is 
probable that the hair-cells, by the friction of their ciliary pro- 
cesses against the reticular membrane or against the rods of 
Corti, transmit these impulses through the nerve filaments 
which they contain, to the receptive centres of the brain. 
Since the endolymph and perilymph are under equal pressure, 
a fact which has been proved by the investigations of Ost- 
mann* it follows that all vibrations of the perilymph will not 
pass the entire length of the scala vestibuli and through the 
helicotrema before exciting similar waves in the fluid of the 
scala tympani, but will pass directly through the two layers 
of the membranous spiral lamina at any point where the resist- 
ance is less than that which must be overcome by the passage 
of the wave through the helicotrema. The fact that the di- 
ameter of this communicating channel is much less than that 
of either the scala vestibuli or the scala tympani increases the 

* Arch, fur Ohrenheilk, vol. xxxiv, p. 35. 






THE FUNCTION OF THE COCHLEA. 



59 



resistance in this direction and favors the passage of the wave 
through the elastic septum dividing the scalas. The inferior 
lamella of this partition is the membrana basilaris, a tissue 
calculated from its structure to be easily affected by changes 
in pressure. Investigation shows that the parallel fibres of 
the membrane are shortest in the lowest part of the canal, 
and gradually increase in length as the spiral ascends. The 
shorter fibres at the base of the cochlea will yield to the pres- 
sure caused by vibrations of short wave length, or those con- 
cerned in the production of the highest notes of the scale, 
while the slower oscillations of the low notes will travel 
toward the apex of the cochlea before displacing the basilar 
membrane. Anatomical structure and physical laws render 
it probable, therefore, that the lowest turn of the cochlea is 
concerned in the perception of the high notes of the scale, 
while the upper turns serve for the recognition of the deeper 
sounds. These deductions have been confirmed by the phys- 
iological experiments of Baginsky.* 

It seems probable that the basilar membrane is the portion 
of the auditory apparatus designed for the analysis and per- 
ception of musical notes as originally suggested by Hen- 
sen, and that the rods of Corti are not directly concerned in 
this process, as Helmholtz at first believed. 

It is quite probable that these rods serve to damp the vibra- 
tions of the membrana basilaris, and to restrict them to limited 
portions for individual notes. The fibres of the basilar mem- 
brane vary in length from .041 millimetre at the base of the 
cochlea, to .495 millimetre at the apex. In number they vary 
from 13,000 to 20,000. It is evident, therefore, that the per- 
ception of the slightest variation in the rates of vibration can 
theoretically be perceived ; practically, differences of one sixty- 
fourth of a tone can be recognized by the trained ear ; in the 
higher registers, differences of half a vibration per second can 
be distinguished by skilled musicians. 

Nothing has been said in the preceding pages about the 
influence exerted upon the transmission of fluid waves by the 
communication between the endolymphatic and perilym- 
phatic channels and the intracranial lymph spaces. It is 
probable that, owing to the small calibre of the communicat- 
ing canals, the friction of the fluid is so great that their pres- 



* Arch, fiir Ohrenheilk, vol. xxiv, p. 54. 



60 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

ence is no protection against a sudden increase in tension 
of the labyrinthine fluid, sudden augmentation in pressure 
being compensated for by the elastic septum covering the 
round window. When, however, the increase in pressure 
within the labyrinth is very slow, such as would result from a 
chronic process within the middle ear with the production of 
new connective-tissue elements, crowding the stapes slowly 
into the oval window, it is probable that the equilibrium of 
the labyrinthine fluid would be preserved, in part at least, by 
its passage into the intracranial lymph spaces. 

The perception of musical notes by the agency of the 
cochlea has been considered first on account of its complex- 
ity ; but it must be remembered that the maculae of the sac- 
cule and utricle and the cristas of the ampullae also contain the 
terminal filaments of the eighth nerve. It is probable that 
noises and perhaps also certain musical sounds are perceived 
here. It would also seem that these structures are particularly 
designed for the reception of vibrations of great amplitude, 
which are interpreted as sound, but that complex sounds are 
not fully analyzed here, although certain variations in pitch 
are recognized. The otoliths are found here and prevent too 
extensive excursions of the ciliae ; their presence in these 
regions alone rather adds weight to the theory that this por- 
tion of the labyrinth is designed for the reception of vibrations 
of considerable amplitude, whether occurring as musical notes 
or following each other irregularly, giving the impression of 
a noise. It seems certain that the ultimate analysis of musical 
tones can only take place in the cochlea ; and hence, from the 
anatomical structure of the parts, the musical notes whose 
perception would be first interfered with in any involvement 
of the labyrinth following a pathological process within the 
tympanum should be those perceived by the basilar mem- 
brane at the lowest part of the cochlea, or that portion close 
to the tympanum. Clinical experience supports this view, 
since in secondary labyrinthine affections we find that de- 
fective perception for the highest notes of the scale is an early 
symptom. 

The Semicircular Canals. — From experiments upon ani- 
mals and from clinical observations it is supposed that the 
semicircular canals are concerned in maintaining the equilib- 
rium of the body, and in recognizing any departure from this 
condition. How much this function contributes to the abil- 



EFFECT OF TYMPANIC CHANGES UPON THE LABYRINTH. 6l 

ity to judge of the location from which a given sound comes 
can not be determined, but it is probable that the position 
which the head assumes, in order that the ear may receive 
the maximum impression of the sounding body, conveys 
to the perceptive centre, through the agency of the semicir- 
cular canals, a certain stimulus which enables the listener to 
locate the approximate position of the sounding body. Re- 
cently Ewald * has attributed to the semicircular canals the 
power of interpreting a sixth special sense, which he denomi- 
nates as the muscular sense or muscle-tonus, holding that the 
perception and maintenance of stable equilibrium are regu- 
lated by the semicircular canals through this special sense. 
Such a claim is difficult to controvert. Any change in muscle- 
tonus must disturb the equilibrium of the body to a certain 
degree, and this in turn would depend for its appreciation 
upon the integrity of the semicircular canals. That these 
portions of the internal ear are the perceptive organs of the 
sixth special sense has not, I think, been conclusively proved. 
The Effect of Changes within the Middle Ear upon the 
Labyrinth. — Since the labyrinthine fluid is separated from the 
tympanic cavity by an elastic membrane at the round window 
and at the oval window by a movable osseous septum, the 
foot-plate of the stapes, it follows that changes in the tension 
of the ossicular chain, due to relaxation or contraction of the 
elastic structures within the middle ear, must cause variations 
of pressure in the labyrinthine fluid. Shortening of the os- 
sicular ligaments and of the tensor tympani muscle will effect 
this change ; or the same result might be brought about by a 
rarefaction of the air within the tympanum, the tension then 
being increased by the atmospheric pressure without. Any 
force acting to displace the foot-plate of the stapes inward, 
causes a similar displacement of the labyrinthine fluid and an 
outward excursion of the membrane at the round window, the 
extent to which this membrane is moved outward depending 
upon its elasticity. Any sudden increase in pressure must be 
compensated for by a corresponding displacement of this 
elastic lamella, since the friction of the fluid against the walls 
of the narrow aqueductus vestibuli and aqueductus cochleae 
would prevent an outward flow in this direction. If the pres- 
sure was maintained for a considerable time, a gradual outflow 

* Physiolog. Untersuch. fiber der Endorg. des Nerv. Octavus. Wiesbaden, 1S92. 



62 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

of fluid through these channels would undoubtedly take place, 
and the equilibrium would be restored. 

Bezold * has shown that the excursions of the membrane 
of the round window are four times as extensive as those of 
the foot-plate of the stapes, in response to any given force dis- 
placing the latter inward. The area of the stapedial foot-plate 
is greater than that of the membrana tympani secondaria, and 
hence displacements of this latter structure must be corre- 
spondingly more extensive. 

When we come to consider the effect of condensation and 
rarefaction of the air in the tympanic cavity upon the tension 
of the labyrinthine fluid, the mechanism of the malleo-incudal 
articulation must be borne in mind. The effect of increased 
aerial pressure within the tympanic cavity would naturally be 
to force the drum membrane outward. This outward move- 
ment would be participated in by the malleus, and through 
its articulation with the incus would be communicated to this 
ossicle, which in turn would cause an outward movement of 
the stapes, with a reduction of the pressure within the laby- 
rinth. From the peculiar construction of the malleo-incudal 
joint, very extensive outward excursions of the manubrium 
cause a separation of the articular surfaces of the ossicle, and 
the stapes is displaced outward to a comparatively slight de- 
gree as compared with the excursion of the membrana tym- 
pani. The membrana tympani has but little elasticity, owing 
to the peculiar structure of the lamina propria, and after the 
maximum outward displacement has taken place it forms a 
rigid wall. Beyond this, any increased pressure within the 
tympanum, due to the introduction either of air or fluid, 
causes an augmentation of labyrinthine tension, the cavity be- 
ing closed on all sides by rigid walls, with the exception of 
those portions of the inner walls occupied by the oval and 
round windows. This increased pressure acts upon both the 
foot-plate of the stapes and the membrana tympani secondaria, 
since they constitute the areas of least resistance, and their 
inward displacement is opposed only by the normal tension 
of the labyrinthine fluid, which is slightly less than that of the 
normal atmospheric pressure. When the pressure within the 
tympanum is increased by artificial means, or as the result of 
pathological processes, and the cavity has attained its great- 

* Politzer, Lehrbuch der Ohrenheilk., Wien, 1893, p, 54. 



EFFECT OF TYMPANIC CHANGES UPON THE LABYRINTH. 63 

est dimensions by the maximum displacement of the mem- 
brana tympani outward, the next result is a displacement of 
the membrana tympani secondaria and of the foot-plate of the 
stapes inward, increasing the tension of the perilymph. The 
movement of the stapes toward the vestibule is permitted by 
the separation of the articular surfaces of the malleus and 
incus. The changes in the endolymphatic pressure are the 
same as those in the perilymph. This explains the phenom- 
enon observed frequently after over-inflation of the tym- 
panum, functional examination indicating increased laby- 
rinthine tension in spite of the fact that the membrana tym- 
pani has been restored to its normal position. 

Politzer* has shown from experiments that aspiration of 
the tympanum — that is, artificially diminishing the aerial 
pressure within it — lowers the labyrinthine pressure instead 
of increasing it. We might suppose at first that this latter 
condition would result on account of the inward displace- 
ment of the ossicular chain from the pressure of the atmos- 
phere. This diminution of labyrinthine tension following 
aspiration of the tympanum is caused by the reduction in pres- 
sure over both the oval and round windows, which more than 
compensates for the inward displacement of the stapes by the 
atmospheric pressure from without. In Politzer's experi- 
ments the pressure within the labyrinth was equal to the 
pressure of the atmosphere, while during life we know that 
it is slightly less than this, and in this condition a moderate 
reduction of tension in the intratympanic air would lower 
labyrinthine tension considerably. As soon as the pressure 
in the middle ear is greatly reduced, labyrinthine tension must 
increase from the extensive inward excursion of the stapes. 
The truth of these conclusions is demonstrated by the effect 
of aspiration and auto-inflation upon the perception of sounds 
of different pitch, as well as the influence which these pro- 
cedures exert upon the conduction of sound through the solid 
media of the skull. It has been proved by Bezold and Sieben- 
mannf that a sudden increase in labyrinthine pressure renders 
the perception of high notes more keen, and increases bone- 
conduction as a rule. The over-inflation of the tympanum has 
been found by the same investigators to effect similar changes. 
Aspiration of the middle ear, on the other hand, according to 

* Op. cit., p. 54. \ Arch, of Otol., vol. xxii, p. 1. 



64 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

Siebenmann,* usually diminishes bone-conduction — a result 
which we should expect from the reduction of labyrinthine 
pressure. The power of hearing high notes is not particu- 
larly affected by this procedure, on account of the short wave- 
lengths of such sounds and the proximity of the area to the 
middle ear of the cochlea specialized for their reception. If 
the perception of high notes is at all affected, it is rendered 
less keen. 

Increased tension within the labyrinth from displacements 
of the ossicular chain inward — a condition which may be 
brought about from a shortening of the muscular or liga- 
mentous structures attached — is corrected, up to a certain 
point, by a displacement of the membrana tympani secondaria 
in the opposite direction. When the limit of its elasticity is 
reached, the perilymph can no longer vibrate. Up to this 
point, however, the entrance of sound waves into the laby- 
rinth is not prevented. Under certain pathological condi- 
tions the membrane of the round window becomes thickened 
and loses its elasticity. When this occurs even a moderate 
displacement of the stapes inward may be sufficient to render 
vibration of the labyrinthine fluid impossible. This rigidity 
at the round window exerts a greater influence when sudden 
changes in labyrinthine tension occur from extensive and 
sudden displacement of the membrana tympani and ossicular 
chain inward, than where these changes come on gradually. 
When the pressure is slowly increased, a compensatory outflow 
of the labyrinthine fluid through the channels of communica- 
tion with the intracranial lymph spaces is possible ; but sud- 
den augmentation of tension can not be relieved in this way, 
on account of the friction of the column of fluid against the 
walls of the capillary passages through which it is forced. 
This explains why we find so great a reduction of the upper 
tone-limit in sudden closure of the Eustachian tube, while 
proliferative changes within the middle ear cause secondary 
labyrinthine involvement only after a long period — in the one 
case, pressure being increased suddenly, in the other case, 
gradually. 

The individual parts of the auditory tract having been 
considered, a few words may not be out of place in review- 
ing its action as a whole. 

* Loc. cit. 



REACTION OF AUDITORY NERVE TO STIMULI. 65 

Under ordinary conditions, sonorous impulses, projected 
through the air, reach the end-organ of the nerve specialized 
for sound perception by the transmutation of aerial waves of 
condensation and rarefaction, through the agency of the tym- 
panic structures, into waves of similar character in the laby- 
rinthine fluid. These waves in turn impress the terminal 
filaments of the auditory nerve in a specific manner. Nor- 
mally, then, sounds are best heard through the air; it is pos- 
sible, however, for the fluid within the labyrinth to be set in 
vibration through the medium of the cranial bones, resulting 
in the phenomenon of sound perception. When the laby- 
rinth is intact, musical notes are interpreted with a fair de- 
gree of accuracy when they reach the labyrinth by bone- 
conduction — that is, when the vibrating body is brought in 
contact with the bones of the head. There are reasons for 
believing that even when the labyrinth is seriously affected 
the auditory nerve itself may react to vibrations which are 
conveyed to it through the bones of the skull. An explana- 
tion of this fact is offered by Gad,* who advances the hy- 
pothesis that under normal conditions the auditory nerve- 
trunk not only transmits stimuli resulting from the analysis 
of complex sounds by the labyrinth, but is also excited by 
the impulses of the vibrating body acting as a mechanical 
stimulus. This last effect will not be prevented by the de- 
struction of the portion of the nerve designed for the analysis 
of sound, the impression received affecting the sensorium as 
a whole rather than as distinct individual notes. The in- 
creased electric irritability of the nerve, so often found where 
the labyrinth has been destroyed in the course of physio- 
logical experiments, rather adds weight to this view. Even 
where the labyrinth is entirely separated from the auditory 
nerve-trunk, the excitation of the nerve by sounding bodies 
of different pitch would probably produce different effects 
upon the perceptive centres, although the exact differences 
could not be defined by the subject. In this hypothesis the 
auditory nerve follows the laws which govern the reaction of 
all sensory and motor nerves to stimuli of various kinds, 
whether they be thermal, mechanical, or electrical. The 
weak point of this theory lies in the fact that in physiological 
experiments one can never be certain that the cochlea has 

* Schwartze, Handb. der Ohren., 1S92, vol. i, p. 34S. 
6 



66 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

been entirely destroyed, while in cases of exfoliation of the 
cochlea in man, as the result of disease, the process has usu- 
ally been unilateral, and the part played by the unaffected 
ear can not be excluded with certainty. Corradi* has demon- 
strated by experiment, that in the porpoise destruction of 
both cochleae causes complete deafness ; but it is not safe to 
say that the same result will follow in the human species. It 
is enough for practical purposes to remember that the exact 
interpretation of sound is only possible when the cochlea is 
intact; while it is probable that the stimulation of the nerve- 
trunk itself may be effected by a sounding body or other 
stimulus, even if the end-organ has been destroyed. 

The Concerted Action of the Auditory Apparatus. — It is 
still a question of dispute as to the exact influence exerted by 
the auditory organ of one side upon that of the opposite side 
of the body. Unquestionably the hearing is most delicate 
when both organs are in perfect condition. If one ear is 
occluded by the finger or obstructed from any pathological 
process, sound perception becomes less acute, and the power 
to distinguish the location of a sounding body is correspond- 
ingly interfered with. No doubt the correlation of the organs 
of the opposite sides depends largely upon the decussation of 
the fibres of the cochlear nerve in the brain, as described in the 
pages devoted to anatomy of the auditory nerve. It must be 
remembered, however, that if perfect audition presupposes the 
anatomical perfection of both organs, a condition might exist 
in which the transmission of sonorous waves by the apparatus 
of one side would be so incorrect as to interfere with the 
perception of those conveyed through the auditory organ of 
the opposite side. Cases are met with in which the hearing 
can be improved by completely occluding one ear artificially, 
thus excluding the sound waves from it. That in the normal 
subject binaural audition is better than monaural is explained, 
according to Urbantschitsch,f by the fact that the stimulation 
of the peripheral organ of the auditory nerve on one side, ren- 
ders the perceptive centre on the corresponding side, and which 
receives fibres from the opposite ear, more susceptible to the 
action of the sound waves. This excitation of the receptive 
centre renders it responsive to slight stimuli reaching it 



* Archiv fiir Ohrenheilk, vol. xxxii, p. I. 

\ Lehrb. der Ohren., Wien, 1890, p. 416. Arch, fiir Ohrenheilk., vol. xxxv, p. 1. 



REFLEX PHENOMENA. 67 

through the opposite ear. In support of this argument, we 
recall the fact that the acuteness of audition upon one side 
for any given sound will be increased if the organ of the 
opposite side is at the same time brought under the influence 
of sound waves of a different character ; thus, for instance, a 
watch may be more clearly perceived in the right ear if a 
vibrating tuning fork is held close to the meatus of the left. 
In this way Urbantschitsch explains the phenomenon of para- 
cousis Willisii, the action of loud sounds serving to stimulate 
the receptive centres, after which relatively feeble stimuli, as 
vibrations of small amplitude, may be perceived. Binaural 
audition, then, would owe its acuteness to the exciting action 
of one auditory centre upon the other. Politzer,* on the 
other hand, believes that the greater acuteness of binaural 
audition depends upon the fact that it represents the effect 
of an impulse acting upon a greater area, and hence pro- 
ducing a more marked impression, upon purely mechanical 
principles. This latter suggestion seems the more simple, and 
yet a close observation of the phenomena produced by vari- 
ous pathological processes reveals the existence of such an 
intimate interdependence between the organs of the opposite 
sides, that it is hard to believe that this association does not 
play an important part under normal as well as under patho- 
logical conditions. 

Reflex Phenomena. — We have spoken at length of the ac- 
tion of one auditory organ upon the other, but it must not be 
forgotten that the nucleus of the eighth nerve of either side 
communicates not only with its fellow, but is intimately asso- 
ciated with the central nuclei of the other cranial nerves, as 
well as with various spinal centres. The function of the ear 
is affected not only by the action of sonorous waves, but also 
reflexly by the action of various stimuli upon other centres 
with which the auditory is in intimate relation. Conversely, 
any excitation of the sound-perceiving apparatus may effect 
psychical, sensory, or motor changes in remote regions of 
the body. The phenomenon, often observed, of starting at 
any sudden sound undoubtedly depends upon reflex action ; 
the association between particular sounds various colors and 
is an example of the curious effect produced on account of 
the communicating fibres between the acoustic and visual 

* Op. cit., p. 516. 



68 THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

centres. On the other hand, the power of audition may be 
perverted or annulled reflexly, by a pathological condition 
affecting fibres of a nerve trunk, the centres of which are in- 
timately associated with the auditory nerve nuclei. 

Phenomena dependent upon Circulatory Changes. — 
Through the intimate relation which exists between the 
blood-vessels of the labyrinth, the tympanum, the higher nerve 
centres presiding over audition and the cervical sympathetic, 
it is plain that circulatory changes must exert an important in- 
fluence upon the function of audition, perverting or impairing 
it, either indirectly by inducing vascular changes within the 
tympanum or directly by causing circulatory changes in the 
end organ or ganglia of the eighth nerve. This fact is to be 
particularly remembered in considering certain subjective 
symptoms frequently complained of, experience showing that 
correction of vaso-motor tone often relieves the manifesta- 
tions. On the other hand, disturbances in the blood supply 
may depend upon actual organic changes in the vessels or in 
the blood itself. It is evident, especially in the consideration 
of subjective phenomena, that there exists a broad field for 
speculation, not only in diagnosis, but also in the selection 
of appropriate therapeutic measures. 

Secondary Phenomena. — In this same line lie those dis- 
turbances, both objective and subjective, which depend upon 
a morbid process in some other organ of the body. Here we 
may mention the symptoms met with in connection with con- 
gestive derangements of the larger viscera, and relieved only 
by remedies appropriate for the correction of the exciting 
cause. Disturbance of the auditory centres in the female is 
not uncommon in uterine and ovarian disorders. 

The relation between ocular and aural derangements has 
lately been emphasized by Oliver and Cleveland ; * many of 
these must be reflex in character. The reflex disturbances of 
the most importance are those occurring in the domain of 
the trigeminal nerve. This nerve supplies many filaments to 
the external and middle ear, and in the latter location, it will 
be remembered, a close association exists between the cranial 
and sympathetic nerves. As a result, any morbid condition 
which involves parts supplied by the trigeminus may, by 

* Burnett's System of Diseases of the Ear, Nose, and Throat. Philadelphia, 1893, 
vol. i, p. 516. 



SECONDARY PHENOMENA. 69 

involvement of the nerve elements which they contain, so 
interfere with the trophic supply of some portion of the ear 
as to cause not only functional disturbances but even organic 
changes in the tissues. 

In this connection the influence of dental caries is the most 
familiar instance, it having been proved that decayed teeth 
may produce not only a functional disturbance of the organ 
of hearing, but also an acute inflammation of the tympanum. 
Most interesting, also, is the close relation between corre- 
sponding parts of the auditory apparatus of the opposite sides 
of the body. Here, no doubt, the phenomena observed de- 
pend upon reflex action through the sympathetic and cranial 
nerves and, in many cases, upon the decussation of the audi- 
tory fibres within the brain. The effect is at first reflex in 
character, but later the result of degeneration or atrophy. 
The so-called " sympathy " between the ear of one side with 
that of its fellow was recognized by Kramer,* Wharton Jones,f 
and many other early writers. Recently Urbantschitsch :£ has 
written extensively upon the subject. 

The effect of increased labyrinthine tension from rigidity 
and displacement inward of the ossicular chain upon the func- 
tion of the opposite ear is made prominent by Weber-Liel * 
and by Cholewa.| The writer A has also called attention to the 
fact, especially in cases operated upon for chronic inflamma- 
tory conditions of the tympanum, that the function of the op- 
posite ear has been improved after operation. Gelle () is in- 
clined to look upon the temporary impairment of function 
observed when the meatus is closed with the finger, while at 
the same time a vibrating body is held close to the unob- 
structed meatus, as due to a reflex contraction of the ten- 
sor tympani muscle upon the non-occluded side, and makes 
use of the experiment to prove the integrity of the upper cer- 
vical nerves, these being comprised in the reflex chain. It 



* Ohrenheilk., 1836, p. 145. 

f Frank's Ohrenheilk., 1845, p. 133. 

\ Arch, fur Ohrenheilk, 1893, vol. xxxv, p. 1. 

# Monatsschr. fur Ohrenheilk, 1874, No. 6. 
I Arch, of Otol., vol. xix, p. 151. 

A N. Y. Eye and Ear Infirmary Reports, vol. i, p. 50, vol. ii, p, 62. Wood's 
Reference Handbook of the Medical Sciences. New York, 1S93. (Supplement.) 
Art. " Middle Ear Operations," 

Arch, fiir Ohrenheilk, vol. xxviii, p. 5S. 



yo THE ANATOMY AND PHYSIOLOGY OF THE EAR. 

seems to me that the manifestation can be better accounted 
for by the direct effect of the pressure upon the end organ of 
the acoustic nerve, and the transmission of the stimulus to the 
perceptive centres of both sides. 

Like other nerves, the auditory trunk may be rendered 
less capable of transmitting impulses either by overuse or 
disuse, and for the same reasons the higher receptive cen- 
tres may cease to functionate properly. Thus, if the ear is 
subjected for a long time to the action of a single sound, this 
particular note will, after a time, cease to be perceived as 
readily as at the beginning of the experiment, although per- 
ception for other notes of the scale will be unaffected. If, on 
the other hand, the nerve is allowed to remain inactive for a 
long period, as where serious obstruction to sound conduc- 
tion has rendered the ear of little practical use, it is found 
that even after the removal of the obstruction and the resto- 
ration of the conducting mechanism to a normal condition, 
the function of the ear is imperfect from the fact that the 
nerve has been so long at rest that it is not able to subserve 
the purpose for which it was designed. On the other hand, 
after the nerve trunk and receptive centres have been once 
excited, they react more readily to stimuli and require less 
energy to maintain them in a condition of irritability than 
would be required to arouse them from a state of repose. It 
is frequently found, in testing the hearing with a watch or 
other similar instrument, that the hearing distance will be 
greater if the sounding body is first held close to the ear and 
then gradually withdrawn until it is no longer heard, than 
if the experiment is reversed : the sounding body being 
gradually carried toward the ear from a point at which it is 
not perceived until a position is reached where it is distinctly 
audible. This means simply that the auditory nerve having 
once been excited, reacts to a stimulus of less intensity than 
that required for its initial excitation. On account of the 
decussation of the auditory fibres in the medulla, it is also 
true that the functional activity of the ear on one side may 
be increased by stimuli directed to the opposite ear. 

Urbantschitsch * explains this upon the hypothesis that the 
excitation of the cortical centre of one side by means of sono- 
rous vibrations acting upon the opposite ear renders sound per- 

* Lehrb. der Ohren., 1890, p. 416. 



HYPERESTHESIA AND PARESTHESIA. 



71 



ception more acute in the other ear on account of the decussa- 
tion of the auditory fibres, through which the cortical centre 
receives fibres from the labyrinth of the corresponding and 
opposite sides. Stimulation of the opposite labyrinth increases 
the irritability of the centre and causes it to respond to a 
slighter stimulus, whether this is received through the cor- 
responding or opposite end organ. I have already suggested 
such an influence in explaining the improvement observed in 
the organ not operated upon in cases subjected to operative 
procedures. Urbantschitsch * has so extended the field of 
possible utility in this direction that it is of the utmost im- 
portance to bear the relation in mind on account of its thera- 
peutic usefulness. This writer urges that this stimulation of 
the perceptive centres may follow the action of sonorous 
vibrations, even if the ear acted upon is so defective as to be 
incapable of transmitting impulses to the degree necessary for 
actual sound perception on the part of the patient. In other 
words, when the organ of one side has been rendered entirely 
useless by sclerotic changes in the conducting mechanism, he 
deems it warrantable to relieve this physical abnormality be- 
fore the influence which it may exert upon the opposite side 
can be decided. 

We have discussed the effect upon the receptive centres 
of overstimulation by sonorous waves, and also the result fol- 
lowing a long period of inactivity. It must be remembered 
that, like other nerve centres, the auditory nuclei and fibres 
react to other stimuli than those for which they were espe- 
cially designed. Pressure upon the terminal filaments, trunk, 
or centre of the eighth nerve excites, perverts, or destroys its 
function. Slightly increased pressure upon the terminal fila- 
ments, from congestion of the labyrinth, may render the nerve 
exceedingly sensitive, and may give rise to subjective noises 
(paresthesias). One of the most curious effects observed 
from this increased activity is the persistence of auditory 
impressions ; for example, when a certain piece of music is 
played upon the piano, the hyperassthetic centre may retain 
a mental picture of this for a long period, and the individual 
be annoyed for hours afterward by the subjective impression 
of hearing the selection continually, exactly as it has been 
played originally. In the same manner it is not an uncom- 

* Arch, fiir Ohrenheilk., vol. xxxv, p. 1. 



7* 



THE ANATOMY AND PHYSIOLOGY OF THE EAR. 



mon experience for patients to aver that they hear the tick 
of a watch even after the sound has ceased, the impression 
once received being maintained for a long interval. It is of 
great importance to bear this in mind in testing the hearing 
with any instrument, such as the watch or acoumeter, where 
the same sound is repeated, as otherwise erroneous conclu- 
sions will be reached. 

Too great stimulation, either on account of the sudden 
condensation of air in the auditory canal, as when a loud ex- 
plosion takes place close to the ear, or by loud sounds con- 
tinued for a considerable period, may cause great impairment 
of hearing for varying intervals of time, the sudden increase 
in pressure, on the one hand, or the prolonged and intense 
excitation on the other, completely destroying either tran- 
siently or permanently the function of the delicate perceptive 
portions of the auditory system. Familiar examples of these 
effects are observed among artillerymen, in whom a tempo- 
rary impairment of hearing is not uncommon, after exercise 
with the great guns of the battery. Among soldiers who 
have been under heavy fire for many days, the prolonged 
and excessive excitation of the receptive centre or of the 
terminal filaments of the nerve has been known to produce 
permanent results, although usually the impairment has been 
but temporary. 



CHAPTER III. 



PHYSICAL EXAMINATION. 



Preliminary Observations. — Before describing in detail the 
instruments needed for the proper examination of the ear, let 
us recall briefly the topography of the region. 

The external meatus is made up of two tubes, joined at an 
angle in both the vertical and horizontal planes, re-entrant 
downward and forward. The fundus of this canal constitutes 
the drum membrane, and is continuous with its cutaneous lin- 
ing. The length of the entire passage, measured from its out- 
ermost point — that is, from the tragus to the drum membrane 
— is thirty-six millimetres, or about one inch and a half. This 
should be remembered as de- 
termining the proper length of 
instruments to be manipulated 
in the meatus. It should also be 
borne in mind that of this inch 
and a half, a little less than one 
inch of the tube is cartilaginous 
and a little over half an inch 
osseous. The general direction 
of the cartilaginous tube is up- 
ward, backward, and inward, 
while that of the bony conduit 
is downward, forward, and in- 
ward. For the satisfactory in- 
spection of the deeper parts, it 
is evident that the axes of these 
canals must be made as nearly as 
possible coincident ; as the out- 
er portion is movable, traction 
upon the auricle upward and 
backward tends to bring the axes into the same straight line. 

Fig. 25 illustrates the position assumed by the parts in the 
adult when the auricle is drawn upward, backward, and out- 
ers) 




Fig. 25. — Pen-drawing from adult 
specimen, showing the result of 
drawing the auricle upward and 
backward. The axes of the bony 
and cartilaginous meatus are made 
coincident, permitttng an inspec- 
tion of the drum membrane (actual 
size). 



74 



PHYSICAL EXAMINATION. 



ward. It will be seen that the cartilaginous and bony meatus 
form practically a straight canal, the angle marking their 
junction having been obliterated by traction in the directions 
named. 

In infants the superior and inferior walls of the meatus are 
in contact and must be separated before the membrana tym- 
pani can be seen. This is due to the absence of the bony 
meatus at birth. As the superior wall of the fibro-cartilaginous 
tube is attached to the squama, the separation of the walls can 
be effected only by traction downward and backward, the in- 
ferior wall being pulled away, so to speak, from the superior 
wall. Fig. 26 clearly demonstrates this fact, and it should be 




Fig. 26. — Drawing from specimen at 
birth. Traction must be made down- 
ward and backward to expose the 
membrana tympani (actual size). 



Fig. 27. — Drawing from specimen from 
child, aged five years. The develop- 
ment of the bony meatus has separated 
the superior and inferior walls, but 
traction downward will still expose the 
membrana tympani most completely 
(actual size). 



remembered that in young children the auricle should be 
drawn outward, backward, and downward in making a specu- 
lum examination. 

In children several years old the development of the bony 
canal has effected this separation of the walls of the deep 
meatus, but even in these cases the membrana tympani is 
more clearly seen if the auricle is drawn slightly downward 
rather than upward. Fig. 27, drawn from a specimen taken 
frVDm a child of five, makes this clear. 

Since the cartilaginous meatus alone is dilatable, the field 
of inspection can not be increased in size by crowding a 



PRELIMINARY OBSERVATIONS. 75 

dilating instrument beyond the osseo-cartilaginous junction. 
On the other hand, since such a procedure fixes the two por- 
tions immovably at their angle of union, the field of inspection 
must be considerably narrowed. Moreover, an instrument of 
greater external dimensions than the calibre of the fibro- 
cartilaginous tube will crowd the soft parts inward toward 
the fibro-osseous junction, and this mass will obstruct the view 
of the deeper parts. 

The fundus of the canal is formed by the drum membrane. 
This is obliquely placed both in the horizontal and vertical 
planes of the long axis of the meatus. The inferior margin 
of the membrane forms an angle with the horizontal plane of 
from thirty to forty degrees, while the anterior margin makes 
an angle oi about one hundred degrees with the vertical me- 
dian antero-posterior plane of the body. From the confor- 
mation of the meatus at its inner extremity, the angles which 
the membrana tympani makes with the posterior and superior 
walls are somewhat greater than those made with the vertical 
and horizontal planes. In other words, the drum membrane 
is really a continuation of the superior wall of the meatus, 
and, to a less extent, of the posterior. From this it follows 
that the superior and posterior margins of the membrane are 
nearer the orifice of the meatus than the inferior and anterior. 
In the young infant the membrana tympani lies in the plane 
of the surface of the squama. To be brought into view the 
operator must direct his glance upward toward the superior 
wall of the canal. 

In investigating diseases of the ear it has been the custom 
to lay special emphasis upon the appearance of the drum 
membrane as observed upon ocular inspection, and to form 
opinions as to the prognosis of any malady largely from the 
information thus obtained. It should be remembered that in 
most cases we are consulted for an impairment or perversion 
of the function of the organ, and hence, while inspection of 
the visible parts is very important and should be made with 
all the skill attainable, it is also equally important to conduct 
a systematic functional examination, for the discovery of the 
location, extent, and nature of the pathological condition re- 
sponsible for the symptoms complained of by the patient, and 
to determine as well to what extent the power of sound per- 
ception is interfered with, the normal ear being taken as the 
standard in conducting such tests. In this manner we can 



yS PHYSICAL EXAMINATION. 

more intelligibly estimate the amount of damage done, and, 
combining the information obtained both from functional and 
physical examination, we arrive at an opinion of greater value 
than that obtained by ocular inspection merely. 

To properly examine the parts so situated as to be open 
to ocular inspection it is necessary to secure a proper illumi- 
nation of the region. From the depth and sinuous course of 
the auditory meatus, examination by direct illumination has 
never been as successful as when the light has been reflected 
upon the parts by means of a mirror. 

The Source of Light. — We have to consider, in the first 
place, the source of light. If sunlight could always be de- 
pended upon it would, no doubt, be the best source of illumi- 
nation for an otoscopic examination. The direct rays of the 
sun, when reflected into the ear, produce such a brilliant illu- 
mination of the parts that detail is obscured. Diffuse day- 
light or light from a white cloud forms a very perfect source 
of illumination, but naturally can not always be obtained. I 
am in the habit, therefore, of advising students to accustom 
themselves to the various appearances as seen by artificial 
light. An ordinary oil lamp, if fitted with a duplex or other 
powerful burner, is an excellent source of illumination. The 
same can be said of an Argand gas-burner; even a common 
candle emits sufficient light to enable the surgeon to make a 
perfect examination, and to perform any operation within the 
canal which an emergency might demand. At least one of 
these means of artificial illumination can be found in any 
house, and familiarity with normal and pathological appear- 
ances when viewed by such light can not fail to be of great 
service to the otologist, who is often obliged to make an 
examination at the bedside. For convenience in making an 
examination at the bedside, as an adequate source of illumina- 
tion may not always be obtainable without delay, or may de- 
mand the aid of an assistant to permit of a proper examination 
without moving the patient, it is well for the examiner to be 
provided for such an emergency. For this purpose use may 
be made of the device shown in Fig. 28, which consists of a 
clamp which may be fastened to a table, chair, the frame of 
the bedstead, or any other firm object in the room, as may 
be convenient. This clamp carries a jointed rod, which sup- 
ports a short arm for holding an ordinary candle. For city 
practice the ordinary fish-tail gas-burner may be substituted 



THE SOURCE OF LIGHT. 



77 



in place of the candle, the burner being attached to a small 
metal band which fits into the candle-holder. This burner is 
connected with a gas fixture in the room by means of a flexi 




Fig. 28— Author's portable illuminating apparatus. In the figure the candle and 
electric lamp are in position ; the gas-burner is shown in the detached drawing 
on the left. 



78 



PHYSICAL EXAMINATION. 



ble pipe attached to it. This apparatus enables one to secure 
a fairly efficient source of illumination and to place the light 
in exactly the position from which he may make the examina- 
tion with greatest comfort to the patient and to himself, and 
renders the entire procedure less laborious and correspond- 
ingly more exact. The entire apparatus occupies but little 
space in the instrument bag, and greatly facilitates bedside ex- 
amination. A small electric lamp suitable for operative work 
can also be attached to the vertical rod, while a light shelf for 
supporting an oil lamp can be fitted upon the arm carrying 
the candle, if the examiner prefers this source of illumination. 

The different appearance of the parts viewed by artificial 
light as compared with the picture seen when diffuse day- 
light is employed, depends upon the fact that all artificial 
sources of illumination contain a preponderance of yellow rays, 
and hence the reds and yellows are slightly exaggerated in 
the otoscopic picture. No mistake need be made if this fact 
is borne in mind, even by an observer accustomed to the 
use of white light. 

Since the introduction of electricity as an illuminating 
agent its employment in otological work has become quite 
common. The rays which the incandescent lamp yields are 
almost colorless, and any desired intensity can be obtained. 
The reflected image of the luminous carbon band sometimes 
gives rise to annoyance — a difficulty which can be obviated by 
the employment of a system of mirrors, the effect of which is 
to obliterate the image entirely and yield only a diffuse white 
light, which the surgeon can then reflect into the ear by means, 
of the mirror. A manifest objection to the electric light lies 
in the fact that it is not always obtainable, although this is in 
a measure overcome by the introduction of portable storage 
batteries. Its greatest advantage is that when ether anaesthesia 
is required, there is no danger of ignition of the vapor, since 
the luminous carbon is completely inclosed. 

As electricity, even when carefully handled, is a somewhat 
capricious agent, it is well for the operator to be supplied with 
an additional source of illumination in every case, so that in 
the event of the electric apparatus failing, some other efficient 
means may be at hand. 

The Reflecting Mirror. — It was formerly the practice in 
examining the ear by means of reflected light, to direct the 
rays into the canal by a plane or concave mirror fixed upon a 



THE REFLECTING MIRROR. 



79- 



short handle (Fig. 29), and held in one hand, while the other 
hand grasped the auricle and supported the speculum in the 
proper position. Obviously the most 
correct information is obtainable by 
the simultaneous inspection and ma- 
nipulation of the parts ; it is necessary, 
therefore, that the surgeon have one 
hand free for the use of a delicate 
probe. At the present day the reflect- 
ing mirror is usually worn upon the 
forehead, and the polished surface is 
concave, thus bringing the luminous 
rays to a focus in front of the mirror. 
The light will be most intense at the 
principal focus of the instrument, and 
the best definition will be obtained at 
a point just within this ; hence the focal 
distance of the mirror should be such 
that when the parts are perfectly il- 
luminated, the eye may be as near as 
possible to the region to be examined, 
while at the same time sufficient space 
intervenes between the ear of the pa- 
tient and the surface of the mirror for 
the manipulation of such instruments 

as it may be necessary to use. It is seldom practicable for 
the eye of the observer to be less than eight or ten inches 
from the deepest part of the region under inspection. In 
selecting a mirror, therefore, the focal distance should not 
be less than seven inches, nor more than eleven inches. This 
fact should be borne in mind in choosing the instrument, and 
can be most easily ascertained by noting the distance between 
the mirror and the hand when the rays of light are brought 
to a focus upon the palm. Where artificial light is used, the 
rays are divergent, and hence the conjugate focus for such 
rays will be more remote than the principal focus, which is 
the point to which the parallel rays are converged. It is also 
advisable to be provided with a mirror which will serve for 
an examination of the ear, and of the nose and naso-pharvnx as 
well. For the inspection of the regions last named the focal 
length of the mirror should be slightly greater than of one 
which is suitable for otological work alone. A mirror of 




Fig. 29.— Hand 



8o 



PHYSICAL EXAMINATION. 




from eight to ten inches focal length for divergent rays is well 
adapted to general use, it being only necessary to move the 
source of light a little nearer the mirror when the throat or 

nose is to be exam- 
ined. 

If the illuminat- 
ing apparatus is pro- 
vided with a con- 
densing lens which 
renders the rays 
parallel, the focal 
distance as deter- 
mined by sunlight 
will be correct ; 
otherwise a mir- 
ror of shorter focal 
length for parallel 
rays than that given 
above should be se- 
lected. It is easy 
to determine wheth- 
er the mirror is per- 
fectly ground by observing the image of the gas flame or 
candle at the focal point of the mirror ; if the rays are 
thrown upon the hand or upon a sheet of white paper, we 
should secure a sharply defined image of the particular flame 
with which we are experimenting ; if the edges of the image 
are blurred, the mirror is practically useless for delicate 
work. The size of the mirror is also important ; those sold 
in the shops are usually perforated in the centre, the mir- 
ror being worn in such manner that the perforation will lie 
over one or the other eye, thus bringing the visual ray of 
the examiner through the centre of the cone of reflected light. 
When the mirror is worn in this way its diameter should not 
be greater than three and a half inches ; a diameter of two and 
a half inches is fully sufficient. 

Certain observers prefer to wear the mirror upon the fore- 
head, in which case the eye of the examiner does not look 
directly through the cone of light, the rays illuminating the 
parts to be inspected being reflected from them at an acute 
angle to the eye of the observer. When this method of exam- 
ination is employed the diameter of the mirror is immaterial. 



Fig. 30. — Reflecting mirror, adapted for use both as a 
head or hand mirror. 



THE REFLECTING MIRROR. 



but nothing is gained by increasing the area of the reflecting 
surface. Still other observers wear the mirror in such way 
that its superior border is below the orbits, the mirror lying 
directly over the nose, and the examiner looks over the top of 
the glass rather than through its centre. It certainly seems 
more simple to perfectly illuminate the parts by the first 
method of examination, since the position which permits of 
the most perfect inspection gives at the same time the most 
perfect illumination. This, however, is a matter of practice, 
and after becoming accustomed to one method of examina- 
tion it is unnecessary to change, equally good work being 
possible by all methods. It should be emphasized, however, 
that the beginner will do well to employ one method con- 
stantly, and not attempt to be- 
come expert at several. 

Sometimes the source of light 




Fig. 31. — Head minor, with nasal support. 



Fig. 32. — Head mirror. 



is an incandescent lamp worn upon the head of the exam- 
iner, the instrument being provided with lenses which focus 
the rays upon the parts to be inspected ; such a light is worn 
either upon the forehead (Fig. 33) or lower down upon the 
bridge of the nose. Considerable practice is necessary in 
order to become expert in the use of such a device for pur- 
poses of examination, even after one is familiar with the use 
of the head mirror. 

The objection to a mirror of large diameter lies in the 
fact that when the central perforation is used, the border of 
the mirror lying close to the uncovered eve interferes with 

7 



82 



PHYSICAL EXAMINATION. 



the perfect relaxation of the organ. This constitutes a source 
of eve strain, and after the instrument has been worn for sev- 
eral hours considerable discomfort is occasioned. 

Regarding binocular inspection of the parts, it is mani- 
festly impossible to view so small an object as the membrana 
tympani. with both eyes through a narrow canal, since the 
length of the canal and the small diameter of the entrance of 
the meatus would render it necessary to have the examiner so- 
far away from the object to be examined, that the exact struc- 
ture could be seen no longer. The eye not in use should be 
completely relaxed, and the beginner should under no cir- 
cumstances close it, as the muscular exertion which this en- 
tails becomes a source of great discomfort after a compara- 
tively short time. When the examiner is accustomed to 
make use of the central perforation in the mirror, and desires 
to use an incandescent light, this may be arranged upon 
a standard as shown in Fig. 28, the rays from the lamp 
beinsr reflected into the canal in the same manner as when 
any other source of illumination is employed. The focal. 
length of the condensing lens under such circumstances is a. 

matter of great im- 
portance : its focal 
distance should be- 
such that the rays- 
are rendered parallel 
or slightly divergent. 
when they strike the 
mirror. If conver- 
gent rays fall upon 
the reflecting surface, 
the result will be that 
the light will be 
brought to a focus 
at a point within the 
true focal distance of 
the mirror, beyond 

Fig. 33.— Electric lamp worn upon the forehead. which point they will 

again diverge, and 
the illumination of the parts will be imperfect unless the head 
is brought so close to the ear as to render instrumentation 
within the canal impossible. Some prefer to wear the in- 
candescent light upon the forehead (Fig. 33), dispensing with 




AURAL SPECULA. 83 

the head mirror entirely, the rays being brought to a focus 
upon the deeper parts within the canal by means of a series 
of lenses of proper curvature. Those accustomed to the use 
of the head mirror upon the forehead will find no difficulty 
in this method of examination. Where one habitually uses 
the central perforation in the mirror, the instrument being 
worn over one eye, considerable practice is necessary to be- 
come expert in using the incandescent light directly. This is, 
in a measure, overcome by making use of a device consisting 
of a head mirror, to the periphery of which a small incandes- 
cent light is attached ; a metallic reflector and shade surround 
the lamp and direct the luminous rays upon the surface of the 
mirror, after which they are thrown into the canal in the 
same manner as when a stationary lamp is used. I repeat 
here, that all electric apparatus is apt to be capricious, and 
that it is well in operating outside of a hospital, where all 
appliances can be obtained at a few moments' notice, to be 
provided with another source of light in case of accident to 
the incandescent lamp. For my own use, the portable stand- 
ard shown in Fig. 28 is so arranged as to support both the 
incandescent lamp and an ordinary gas-burner, the latter 
being connected with any convenient gas fixture in the 
room, and care being taken to have it in perfect working 
order before any operation is begun. The knowledge that 
an accident to the battery or lamp will not prove a source 
of annoyance is a great mental satisfaction to the operator. 

Aural Specula. — In order to inspect the deeper parts of 
the meatus, the membrana tympani, and the tympanic cavity, 
it is necessary to separate the walls of the cartilaginous canal, 
and to overcome the irregularities, at the same time changing 
the axis of this tube to correspond with that of the osseous 
meatus. This latter object is attained by traction upon the 
auricle in a direction upward, backward, and outward, while 
the walls of the canal are at the same time separated and 
maintained in a position by the aural speculum. These in- 
struments may be made of hard rubber, metal, or even of 
stiff paper, and vary in shape. Individual choice plavs a 
prominent part in the selection of the particular form of 
instrument to be employed, but certain rules, applicable to all 
instruments of this character, must be borne in mind. The 
material of which the speculum is made must be as thin as 
possible, in order to secure the maximum field of inspection ; 



84 



PHYSICAL EXAMINATION. 



many of the instruments sold are so thick and heavy that, 
although the outside diameter is comparatively large, the 
calibre is very small, and when the meatus is narrow an 
instrument that can be introduced with comfort to the pa- 
tient yields but a small area for inspection. Care should 
be taken that the end of the instrument inserted into the 
meatus has a perfectly smooth margin, as any irregularity 
of outline is sure to cause discomfort to the patient, and in 
children, to begin with an unfortunate accident of this kind 
may render an examination almost impossible. The length 
of the speculum is also a matter to demand attention. It 
is essential that the instrument shall project no farther be- 
yond the entrance of the meatus than is necessary to per- 
mit of its being firmly held, since the difficulty of examina- 
tion becomes greater when the observer is obliged to direct 
the light through a long, narrow passage to illuminate a 
small area at its extremitv, and at the same time recognize 
minute variations in the condition of the parts. Under the 
most favorable circumstances the meatus itself presents ob- 
stacles which render an exact interpretation of the conditions 
observed very difficult, and to increase the length of the 
passage is to add greatly to these. The speculum should 
be just long enough to allow the surgeon to hold it firmly 
when in position and no longer. It is also important that 
the portion of the tube introduced into the canal should 
taper slightly, since the deeper parts are less distensible than 
those more superficial!} 7 placed, and if the speculum fills the 
canal completelv it can not be tilted in different directions, 




Fig. 34. — Politzer's hard rubber 
auial speculum. 



POO 




Fig. 35. — Wilde's aural 
speculum. 



so as to bring the various portions of the fundus into view. 
The exact shape is unimportant ; some examiners prefer an 
instrument the orifice of which is circular in outline, while 
others advise that it be oval, corresponding in form to the 
lumen of the canal as seen in cross section. The instrument 



AURAL SPECULA. 



85 



bearing- the name of Wilde is conical, and the orifice circular, 
while in Gruber's speculum the tube is oval on cross section, 
and instead of being conical is somewhat funnel-shaped. This 
last feature is observed in the instruments of Troeltsch, Bou- 
cheron, Toynbee, Politzer, and others. Many prefer a single 
instrument which can be adjusted to the lumen of any canal 
by means of a set screw, the device resembling in construe- 



POO 





Fig. 36. — Gruber's aural specu- 
lum. 



OOO 

Fig. 37. — Toynbee's aural specula. 
(The instruments are too long, and 
the cut is introduced to show this.) 



tion the bivalve speculum of the rhinologist. In some in- 
stances it is advantageous to have one wall of the tube cut 
away for a certain distance in order that the meatus may be 
inspected after the instrument has been inserted. This end is 
best accomplished by employing a wire speculum, the walls 
of the meatus being separated by the elasticity of the mate- 
rial of which it is constructed. In an emergency a very serv- 
iceable speculum can be made with a piece of stiff note paper, 
twisted into the form of an elongated cone, the free edges of 
the paper being secured by a pin, a stitch, or by mucilage. 
This cone is then cut off at such a distance from the apex as 
will allow it to be easily inserted into the meatus, while in 
the other direction it is so cut as to reduce it to a proper 
length. Such an improvised instrument answers perfectly well 
not only for diagnosis, but also for operative purposes. In 
fact, I frequently use them in preference to metal specula, even 
when the latter are at hand. Their chief advantage is their 
cleanliness, the same cone never being used a second time. 

Whatever form of speculum may be chosen, attention to 
the above points will result in the selection of a serviceable 
instrument. Exact shape is immaterial, as constant use will 
soon enable the surgeon to become expert with any one of the 
various varieties. One possible advantage possessed bv the 
funnel-shaped instruments, in which the outer opening is very 
wide, is that the examiner can more easily direct the light 
into the speculum than when the smaller instrument of Wilde 



Sf PHYSICAL EXAMINATION. 

is used. Whether the interior of the instrument is polished 
or blackened also ce;;ends upon individual preference. The 
contrast :: the black background may be an advantage, but a 
certain amount :: brilliancy c: illumination is sacrificed. 

It is necessary to be creviced with specula of various sizes, 
and at least three are necessary to meet the differences in 
diameter of :ne Mince of the meatus, while five or six sices 
are still more advantageous. The proper diameter, accord- 
ing t: Richards.* of the smaller end of each speculum in a 
set of five of the Wilde pattern is given below, and will be 
found valuable : ~ mm.. 6 mm., _fc mm.. 4 mm.. y : mm. 

Being provided with a satisfactory source of light, a 
proper head mirror, and a suitable speculum, the next step 
will be the technique of tine examination. 

The Technique of Examination Fig. 5 S . — The patient and 
examiner may both be seated, a position which I decide fly 
f refer, or both may stand, or the patient may sit while the phy- 
sician remains standing. The patient is best seated in a high- 
backed chair, in an attitude which can be maintained for some 
time without discomfort, the head resting against the back of 
the chair, the affected ear being turned toward the examiner. 
Tine surgeon, either sitting or standing, should occupy a posi- 
t::n to the right 0: the patient rather than directly facing the 
affected side. Sitting or standing, this latter position must 
be an awkward one. and in the event of the examiner prefer- 
ring to remain seated, necessitates the separation of his knees 
wifely, so that the chair of the patient is between them. 
This posture is not only uncomfortable, but for tovious rea- 
sons undesirable. Moreover, the operator is not able to fol- 
low any sudden motion of the patient's need when seated in 
this manner, since he is working at arm's length. When the 
other position is emploved. a slight motion of the arm enables 
the operator to so follow any sudden movement which the 
patient may make on account :: fear or pain that the exact- 
ness :: tne manipulation is in no way disturbed. 

Tine light should be placed, preferably, on the left of the 
examiner, and slightly above the horizontal plane passing 
through the ear to be examined. In this manner anv ma- 
uij illation of instruments with the right hand will not inter- 
fere with the rays passing from the lamp to the mirror. 






TECHNIQUE OF EXAMINATION. 



87 



The patient, surgeon, and source of light being satisfac- 
torily arranged, it should be the invariable rule to examine 
the auricle, the entrance of the meatus, and the cartilaginous 
■canal to as great a depth as possible before the speculum is 
introduced, as the speculum may conceal some pathological 
condition at the very entrance of the meatus unless this rule 
is followed. In order to examine the cartilaginous canal and 
to prepare for the insertion of the speculum, the auricle should 
be grasped firmly but lightly at its upper and posterior mar- 
gin between the third and fourth fingers of the left hand, and 




Fig. 38. — The ocular inspection of the membrana tympani, showing the position of 
the patient, the surgeon, the source of light, and the manner of holding the 
speculum. 

traction should be made upward, backward, and outward. In 
examining the right ear the hand lies behind the auricle ; in 
examining the left ear it lies above and anterior to it. In this 
manner a fairly good view of the external portion of the meatus 
is obtained, and any irregularities in size and shape may be 
noted as well as any deviation from the usual direction. The 
information thus derived enables the investigator to select a 
speculum of appropriate size, which should be grasped lightly 
between the thumb and index ringer of the left hand, warmed 
over the lamp, and then introduced into the canal as lightly 
as possible. To effect this the operator holds the speculum 
between the thumb and index finger, grasping the auricle, 



88 PHYSICAL EXAMINATION. 

as before., between the third and fourth fingers of the left 
hand. While the auricle is drawn upward, outward, and 
backward, the dilating instrument is gently introduced into 
the meatus, is advanced gradually by rotation upon its long 
axis, it being rolled, so to speak, between the thumb and index 
finger, while at the same time it is pushed inward. Care should 
be taken not to pass the instrument beyond the cartilagi- 
nous canal, since this is not only painful, but interferes with 
the mobility of the outer portion of the meatus, and hence 
limits the area exposed for inspection. The speculum must 
be of such a size that the walls of the canal are simply sepa- 
rated by it and not stretched, as this interferes with the mo- 
bility of the membranous portion of the canal and prevents 
it being so manipulated as to make its axis coincide with 
that of the bonv meatus. When the speculum is too large 
the soft parts are so crowded in front of it that the full lumen 
of the speculum is not available and the field is narrowed in 
consequence. 

The speculum having been properly inserted, the observer 
should first bring that part of the superior wall of the canal 
into view which lies just beyond the inner extremity of the 
speculum. This is done by carrying the thumb and index 
finger which hold the instrument downward, thus tilting the 
inner extremity upward. Having recognized the superior 
wall of the meatus, the anterior, inferior, and posterior walls 
are successively brought into view by causing the outer end 
of the speculum to describe a circle in the direction named, 
the fixed point being the inner extremity of the instrument. 
This manipulation is accomplished by a slight movement of 
the thumb and finger which grasp the outer end of the specu- 
lum, the digits being alternately flexed and then gradually 
extended until the extremity of the instrument has described 
a complete circle. In conducting this manipulation each 
wall of the meatus should be inspected throughout its entire 
extent, from the inner end of the speculum to where it joins 
the tympanic ring. 

Attention should be paid during this procedure to the fol- 
lowing points regarding the canal : Whether it is free through- 
out its entire length, or partially or completely obstructed. 
If the lumen is encroached upon, information should be ob- 
tained as to the nature of the obstruction, whether it be a for- 
eign body accidentally or intentionally introduced, or whether 



TECHNIQUE OF EXAMINATION. 89 

it is made up of a mass of impacted secretion, whose source 
is the ceruminous glands of the meatus, or of epithelial debris, 
the result of an inflammatory process, or of a parasitic growth 
which has proliferated in this locality. On the other hand, 
the deeper portion of the canal may be filled with fluid, either 
pus, serum, mucus, or blood. Again, the lumen of the canal 
may be encroached upon only over a certain circumscribed 
area, in which case the probe determines the density of the 
obstruction — whether it is hard or soft, tender or anaesthetic, 
whether invested with normal epithelium or presenting a de- 
nuded surface. Its location should always be carefully noted, 
whether it is situated in the deeper portion of the canal or 
near the orifice. In other cases the canal may be narrowed 
uniformly throughout its entire extent. Here the density of 
the walls as determined by the probe is of service, as well as 
the appearance of the outer surface. None of these more evi- 
dent abnormal conditions existing, the observer should in all 
cases note the condition of the integument lining the canal, 
determining whether it is dry and desquamating in places, or 
moist and reddened, or covered here and there with masses of 
dry secretion forming crusts upon the walls. Having critic- 
ally observed these different physical conditions, the superior 
wall of the meatus should be followed inward, the angle of 
the speculum being gradually changed so as to bring the 
deeper portions into view until this aspect of the canal merges 
into the membrana flaccida. The outer end of the speculum 
being still further elevated, the eye next recognizes the epi- 
dermal covering of the membrana tympani and follows this 
until it passes quite abruptly into the inferior wall of the 
meatus. An examination in this manner — the superior wall 
being followed across the fundus of the meatus until the eye 
looks upon the inferior wall, and the posterior wall traced 
until it merges without a break into the anterior — demonstrates 
with certainty that the membrana tympani is present, and, if 
no solution in continuity has been observed, intact. This is 
the most satisfactory method of demonstrating that the mem- 
brana tympani is present and unbroken throughout its entire 
extent. Whenever there is a solution of continuity this regu- 
lar outline must be broken. In some cases, where the mem- 
brane is almost completely destroyed and is replaced by cica- 
tricial tissue which applies itself closely to the internal wall of 
the tympanum, a mistake may be made; this is scarcely pos- 



90 



PHYSICAL EXAMINATION. 



sible, however, if an exhaustive examination is made, each 
wall being followed until it merges into the one directly op- 
posite. When the membrana is extensively destroyed, as 
mentioned above, we find usually at some point along the 
posterior wall that the fundus of the canal is not continuous 
with this wall, but that there is a solution of continuity at the 
inner extremity, the epidermis not passing directly from the 
posterior wall of the canal to the promontory, but that a cer- 
tain space is left between these two regions, the width of the 
hiatus being easily recognized by the practiced eye. I have 
given this as one of the early steps in conducting the examina- 
tion, since the observer more readily analyzes appearances 
met with if the question of presence or almost complete de- 
struction of the drum membrane has been settled before other 
points are considered. 

We must next recognize certain landmarks at the fundus 
of the canal, which under normal conditions is occupied by 
the membrana tympani (Fig. 39). As the superior wall is fol- 
lowed inward, there will be seen just below the centre of the 
line marking its inner termination, a prominent projection, 
white or grayish white in color, having the appearance as 
though the soft parts covering it were pushed outward into 
the lumen of the canal by some firm body beneath. This pro- 
jection is the short process of the malleus, and its position 
changes but little, no matter how much the entire ossicle may 
be displaced by rotation about the axis from alterations in 
tension of the intratympanic ligaments and muscles. More- 
over, this portion of the ossicle is richly supplied with nutrient 
vessels, and even when there is extensive caries of the tym- 
panic walls and of the ossicular chain, it usually escapes dis- 
integration. Under normal conditions the short process of 
the malleus appears as a prominent point, about the size of a 
pinhead, varying in color from a chalky white to a grayish 
white or even pinkish white. Extending downward and some- 
what backward from this point, through the middle of the 
membrane as far as its centre, the handle of the malleus is 
recognized. This process tapers gradually as it passes down- 
ward. At its lower extremity it is flattened slightly from 
without inward, and appears a little broader than just above 
its termination. The shaft of the malleus is slightly curvi- 
linear in outline, the convexity being toward the meatus in 
the upper two thirds, while at the lower third it is directed 



THE MEMBRANA TYMPANI. 



91 



inward and somewhat backward, lying more nearly in the 
plane of the membrane. The outline of the shaft, under normal 
conditions, appears somewhat darker than the surrounding 
membrane, its presence offering an obstruction to the rays of 
light illuminating the fundus of the canal. The outline of the 
shaft is not infrequently slightly pinkish instead of white, and 
occasionally one or two blood vessels may be recognized trav- 
ersing the membrane close to the manubrium and parallel to 
it. This is particularly true if the speculum has remained in 
the canal for some time, and depends upon the venous con- 
gestion incident to the presence of the foreign body. The 
flattened termination of the manubrium at the centre of the 
membrane is known as the umbo. Under normal conditions 
the eye perceives a bright triangular area upon the surface of 
the membrane, extending from the umbo downward and for- 
ward to the periphery, the apex of the triangle lying at the 
umbo, while the base of the triangle does not extend to the 
periphery, but fades away gradually before it reaches this 
line. It is evident that if we imagine the malleus handle to 
be prolonged to the periphery of the membrane, this struc- 
ture will be divided into two portions — one in front and 
the other behind the line, the posterior portion being the 
larger. If a horizontal line is drawn through the umbo to the 
anterior and posterior walls of the canal, these two segments 
will be again divided into two. For convenience in locating 
pathological appearances we conceive the drum membrane to 
be so divided, the segments being named the superior anterior, 
inferior anterior, inferior posterior, and superior posterior 
quadrants according to their situation. From the short pro- 
cess of the malleus two bands are observed, 
one running backward, the other in the op- 
posite direction, to the periphery of the 
membrane. Of these-, the posterior is the 
longer, the anterior being just barely seen 
under normal conditions owing to the prox- 
imity of the short process of the malleus to f ig> 39 —The normal 

the upper anterior extremity of the tym- membrana tympani 
. x . ...". (somewhat diagram- 

panic ring, and because 01 the obliquity matic). 

of the plane in which the membrane lies. 

These bands are called the anterior and posterior folds of the 

membrane. They are caused by the difference in tension 

between the membrana tensa below and the membrana flac- 




02 PHYSICAL EXAMINATION. 

cida above. These bands are sometimes very well marked, 
while in other instances they are not distinct. 

Between the short process of the malleus and the superior 
wall of the meatus the membrana tympani presents a distinctly 
triangular form, the apex of the triangle lying at the short 
process, from which point the sides of the triangle diverge 
until they are lost in the superior wall of the canal, into 
which they pass without any distinct line of demarcation. The 
sides of the triangle are clearly marked by a thickening along 
the lateral boundaries of this triangular area. This upper 
portion of the drum membrane is the membrana flaccida, or 
Shrapnell's membrane, and the fibres which form the sides 
of the triangle are known as Prussak's fibres. It will be re- 
membered that the tympanic ring is wanting at Shrapnell's 
membrane, the curvilinear outline being completed by the 
free border of the outer lamella of the squamous plate of the 
temporal bone, which fills up the gap between the anterior 
and posterior limbs of the annulus. The name of Rivinian 
fissure or segment has been given to this dehiscence in the 
annulus tympanicus. It is also to be borne in mind that the 
lamina propria of the drum membrane is wanting over this 
area, the septum being completed by the tegumentary lining 
of the canal which passes downward over the Rivinian fis- 
sure, its epithelial layer being continued over the surface of 
the membrana tympani. 

Having determined that the membrana tympani is intact, 
or, if any solution of continuity exists, the extent and location 
of the defect having been made out, the observer should next 
note the following physical properties of the membrana or of 
its remaining portion : i. The color. 2. The lustre. 3. The 
structure. 4. The position. 

The Color. — The normal membrane is of a pearly- white 
appearance, with a slightly bluish tinge over the entire mem- 
brana tensa ; above the folds the parts may have a faint pink- 
ish hue, even when in a healthy condition. 

The Lustre. — The recognition of variations in the lustre of 
the drum membrane constitutes one of the most valuable aids 
in the diagnosis of aural affections. Normally the parts pos- 
sess a peculiar sheen which can not be described in words, 
but is easily recognized when once seen. The triangular light 
spot has already been spoken of, and its persistence or ab- 
sence, the variations in shape, position, and extent, and the 



THE MEMBRANA TYMPANI. 



93 



presence of one or more bright points or light reflexes in other 
parts of the membrane, all furnish valuable information. The 
lustre may be diminished or may be entirely wanting, this 
latter condition always indicating a necrosis of the superficial 
epithelium. 

The Structure. — Under this term we consider the devia- 
tions from the normal appearance resulting from changes in 
the various layers of the part under examination. In health 
the membrana vibrans is of uniform texture throughout, ex- 
cept at the periphery and at the umbo, in which localities it 
is somewhat thickened and consequently less translucent than 
elsewhere. The eye is also able to make out indistinctly the 
circular and radiating fibres as they cross one another, giving 
an appearance suggestive of a finelv woven fabric. Under 
pathological conditions the membrana propria may undergo 
hypertrophy in places, in which case the uniformity of tex- 
tural appearance will be lost and the affected areas will appear 
less translucent than the surrounding portion. The same ef- 
fect is produced, but in a more marked degree, by calcareous 
deposits in the fibrous layer. These appear as opaque, lustre- 
less white areas, with well-defined outlines. On the other hand, 
as the result of pressure, cicatrization after loss of substance, 
etc., the fibrous layer may be very thin or even wanting in 
certain localities. Here the membrane will be transparent, and 
through the thin septum the underlying structures within the 
tympanum may be easily recognized. The membrana flaccida, 
containing no lamina propria, does not exhibit the peculiar 
woven appearance characteristic of the larger segment of the 
drum membrane ; its appearance is similar to that of the skin 
lining the adjacent part of the bony meatus, except that it is 
more delicate in structure. Owing to pathological changes 
it may become transparent and parchmentlike, or its thick- 
ness may be greatly increased. 

The Position. — Normally, the drum membrane is inclined 
both in the horizontal and vertical planes. In addition to this 
it is drawn inward at the umbo on account of its intimate con- 
nection with the manubrium mallei. The inclination in two 
planes, together with the umbilication at the centre, gives rise 
to the light reflex, the rays illuminating this area alone be- 
ing reflected directly back to the eye of the observer, without 
previously impinging upon the walls of the canal. Another 
result of the umbilication is to give to each segment of the 



94 



PHYSICAL EXAMINATION. 



membrana a slightly convex appearance when viewed from 
the canal, which is most marked in the upper and posterior 
quadrants. In the young child the inclination of the mem- 
brane in the horizontal plane, as viewed through the meatus, 
appears more pronounced than in adult life. This greater in- 
clination is more apparent than real, depending upon the spe- 
cial conformation of the parts at birth. At this period, it will 
be remembered, the superior and inferior walls of the meatus 
are in contact, the superior wall lying upon the external sur- 
face of the squama while the bony meatus does not exist, be- 
ing represented by a canal of fibrous tissue, especially well 
developed along the inferior wall. 

Having reviewed the appearance of the membrane under 
normal conditions, we are now prepared to recognize varia- 
tions caused by morbid processes. As the upper and posterior 
part is nearest the eye of the observer, and as this is the most 
extensive segment of the membrane, displacement of the entire 
membrane outward in this region is more apparent than else- 
where. If displacement be excessive the bulged posterior por- 
tion may overhang the anterior segment and partially or com- 
pletely obscure it. Sometimes the effect is to obliterate in this 
region the line of demarcation between the canal wall and the 
drum membrane, giving to the fundus a narrow appearance. 
On the other hand, marked retraction obliterates the normal 
prominence of the upper and posterior segment and exagger- 
ates the inclination of the upper part of the membrane in the 
horizontal plane, at the same time causing the inferior segment 
to appear more nearly perpendicular to the inferior wall of the 
canal. It also tends to exaggerate the apparent width of the 
drum membrane on account of the greater depth of the tym- 
panum above and behind, which allows the membrana to move 
inward for a considerable distance, thus bringing the anterior 
segment into view. As seen through the speculum, this in- 
crease in the transverse diameter, especially of the inferior 
segment, is exceedingly well marked. The most valuable in- 
dication of retraction, however, is afforded by a careful inspec- 
tion of the malleus handle. This prominent and easily recog- 
nizable landmark appears foreshortened in direct proportion 
to the degree of retraction, provided adhesions between it and 
the inner tympanic wall do not exist, and prevent it from as- 
suming the usual position which it occupies when the pressure 
within the tympanic cavity is lowered. Another evidence of 



OBSTACLES TO EXAMINATION. 95 

extreme retraction is the prominence of the curved margin of 
the tympanic ring, which can frequently be traced throughout 
its entire circumference when the membrane is displaced in- 
ward to a marked degree. It sometimes happens, owing 
to the presence of adhesions, that the handle of the malleus is 
not foreshortened; then the displacement of the segments of 
the drum membrane in front and behind the manubrium, to- 
gether with the marked prominence of the annulus and the 
ease with which the intratympanic structures are seen, enable 
the observer to interpret the condition correctly. When the 
malleus handle is firmly bound down and the air within the 
tympanic cavity is rarefied, the anterior and posterior seg- 
ments of the drum membrane collapse, and the manubrium 
appears as a prominent ridge between the sunken areas. In 
front, behind, and below this ridge there are deep pits or fossae, 
where the more elastic membrane has been forced inward by 
the pressure of the air until it has impinged upon the inner 
tympanic wall. In children this condition is very prone to 
exist where adenoid vegetations are present. The appearance 
is not infrequently a source of error in diagnosis, being mis- 
taken for a total destruction of the membrana vibrans and 
a subsequent dermoid transformation of the inner tympanic 
wall. 

Obstacles to the Examination. — The description given of 
the technique of the inspection of the ear by means of re- 
flected light, presupposes that an unimpeded view has been 
possible ; occasionally, however, obstacles are encountered 
which render the inspection of the deeper parts difficult 
Here we may mention the presence of fine hairs in the meatus 
preventing a perfect illumination of the membrana tympani. 
In such an event the examiner, after the insertion of the 
speculum, will find it advisable to apply a little vaseline or 
wax to the hairy area by means of a cotton-tipped probe ; by 
this procedure the hairs are made to adhere closely to the 
wall of the canal, and are prevented from interfering with 
the examination. If the orifice of the meatus is exceedingly 
narrow, either as the result of congenital malformation, cica- 
tricial contraction, or an acute circumscribed inflammatory 
process, the examiner will do well to use an exceedingly 
small speculum. By tilting the instrument at various angles 
it will be possible to inspect the deeper parts over successive 
small areas until the necessary information has been obtained. 



96 PHYSICAL EXAMINATION. 

This is wiser than to attempt to use a large instrument which 
fits the canal closely, in the hope of obtaining a more ex- 
tended field of view. 

The prominence of the antero-inferior wall occasionally 
offers an obstacle to perfect inspection of the deeper parts ; 
but here again the small speculum will enable the observer 
to see a more extended surface than a larger instrument, 
provided the auricle is drawn upward and backward suffi- 
ciently to permit the illumination of the parts beyond the 
obstructing canal wall. In the same manner, if the orifice of 
the meatus is almost closed, as the result of an acute inflam- 
matory process, and the parts are excessively tender, it is pos- 
sible, by exercising a little care, to introduce a small specu- 
lum beyond the inflamed area, and to obtain a view of the 
deep parts. It is to be remembered that no bony meatus 
exists at birth, and the membrana tympani lies superficially 
and in nearly the same plane as the superior wall of the canal, 
which is closely attached to the outer surface of the squama; 
hence, to obtain a clear view of the membrane, the auricle 
must be drawn downward and backward instead of upward 
and backward, as in the examination in an adult (Fig. 26). 

In addition to what has already been said concerning the 
recognition of the various normal and pathological condi- 
tions, it is necessary to call attention to special portions de- 
manding particular investigation ; these are the periphery 
of the membrane, and that area lying above the level of 
the short process, the membrana flaccida. It is quite pos- 
sible to recognize all the conditions enumerated in the pre- 
ceding pages and yet to overlook a small perforation, unless 
the examiner, as a final step, inspects the entire outline of 
the annulus, following with the speculum the line of attach- 
ment of the membrane throughout its entire circumference. 
Again, that region situated above the short process of the 
malleus and the folds of the membrane demands careful at- 
tention, since it covers the articulation between the malleus 
and the incus, and that portion of the tympanum where the 
mucous lining is thrown into numerous folds as it passes 
from the bony walls of the cavity over the intratympanic 
ossicles and ligaments. It is not uncommon to find a minute 
perforation through the membrana flaccida, which might pass 
unrecognized unless special attention had been directed to 
the inspection of this locality. It should be borne in mind in 



TYMPANIC TOPOGRAPHY. 



97 



this connection that we occasionally meet with a minute open- 
ing, just above the short process of the malleus. This was 
formerly supposed to be occasioned by the incomplete closure 
of the Rivinian segment. A small opening at this point is, 
according to Randall,* due to a pathological process, and 
there is no foundation for considering it a result of imperfect 
development. Under all circumstances both ears should be 
examined, although the patient may complain of but one. 
The importance of this is evident if the reader will recall 
the remarks already made in the chapter on physiology, con- 
cerning the interdependence of one organ upon that of the 
opposite side. It is also important, since any slight anomaly 
in the direction of the canal or in the position of the mem- 
brana tympani will probably exist on both sides, and a source 
of error in the interpretation of appearances found in the 
affected organ will thus be removed. 

At this point we should consider the relation between the 
contents of the tympanum and the various quadrants of the 
tympanic membrane. 

Fig. 12 represents the intratympanic structures and the 
inner wall of the middle ear, the ossicles lying in their nor- 
mal position. A portion of the inferior and posterior wall of 
the canal is shown. The membrana tympani, with the excep- 
tion of a small crescentic portion posteriorly, has been re- 
moved and the contents of each quadrant can be easily made 
out. 

In the supero-posterior quadrant the long process of the 
incus is seen descending in a direction parallel to the manu- 
brium mallei, lying behind it and at a deeper level in the 
tympanic cavity. The articulation of this process with the 
head of the stapes is also seen, together with the posterior 
cms of this latter ossicle, which passes upward and inward 
until it is lost in the oval niche. From the head of the stapes 
a delicate fibrous band is observed, which extends directly 
backward until it is lost from view behind the margin of the 
tympanic ring. This is the tendon of the stapedius muscle. 
The tip of the descending crus of the incus (and hence the 
incudo-stapedial articulation) may frequently lie at a consid- 
erable distance below the level of the short process of the 
malleus. On the other hand, and especially as the result of 

* Trans Am. Otol. Society, 1S94. 



98 PHYSICAL EXAMINATION. 

a pathological condition, this process of the incus may run 
almost horizontally inward, the processus lenticularis being- 
hidden behind the supero-posterior margin of the bony ring. 
In such an event the stapes itself and the stapedius tendon are 
out of the range of vision. Another situation frequently oc- 
cupied by this process of the incus is close to and just behind 
the posterior margin of the bony ring. It passes downward 
in a direction parallel to the posterior limb of the annulus, and 
is brought into view if the patient's head is turned away from 
the examiner, permitting the illuminating rays to pass behind 
the projecting margin of the ring. This position of the incus 
is usually the result of contraction of the stapedius muscle 
or of shortening of its tendon. Search with a delicate probe 
reveals the location of the crus of the incus, the instrument 
being easily hooked about it and drawing it into view. If 
firmly fixed, the division of the stapedius tendon or of dense 
adhesions passing backward from the posterior crus of the 
stapes releases it and brings it into the field of vision. The 
upper and posterior quadrant, since it contains structures so 
important to the function of audition, should always be closely 
examined, whether the membrana tympani is intact or par- 
tially destroyed. Frequently the attenuation of the mem- 
brana in this locality, either from cicatrization or atrophy, 
enables the observer to recognize the above-mentioned parts 
through it. This is particularly so when there is consider- 
able retraction of the drum membrane, which then applies 
itself closely to the structures beneath. 

Below the incudo-stapedial articulation in the lower part 
of the supero-posterior quadrant, and encroaching to a greater 
or less extent upon the postero-inferior quadrant, is seen a 
deep niche the posterior boundary of which is hidden by the 
margin of the annulus tympanicus, while the anterior mar- 
gin forms the postero-inferior boundary of the promontory. 
At this line the inner tympanic wall bends at almost a right 
angle, and the plane of the niche is directed backward and 
downward. The depression formed by this sudden bend is 
the niche of the round window. Sometimes it lies entirely 
behind the margin of the ring and out of the field of vision. 
The portion of the tympanic wall occupying the middle of 
the field of inspection is the promontory. It covers the first 
turn of the cochlea, and exhibits a convex surface which en- 
croaches to a varying extent upon the the cavity of the tym- 




TYMPANIC TOPOGRAPHY. 99 

panum. When this portion of the wall is unusually convex, 
and the niche of the round window can be seen, the pro- 
jecting mass will occasionally be mistaken for an exostosis 
unless the possibility of its anomalous prominence is borne 
in mind. The region corresponding to the antero-inferior 
quadrant presents nothing demanding special notice, except 
that the tympanic opening of the Eustachian tube may en- 
croach upon its upper part. In the majority of cases the 
tympanic orifice of the tube lies in the upper anterior quad- 
rant and may be entirely concealed by the anterior border of 
the tympanic ring. 

When the membrana vibrans is absent it is possible to 
pass a delicate probe, bent at a right angle at the tip, upward 
into the vault of the tympanum, both in front and behind the 
short process of the malleus, the angular portion disappear- 
ing completely in the upper 
tympanic space. Traction 
outward causes the bent part 

Of the probe tO press upon FlG 4a _Middle ear probe. 

the inner extremity of the su- 
perior wall of the canal, and the instrument can not be re- 
moved by traction directly outward, it being necessary first 
to disengage its tympanic extremity from the inner margin 
of the superior wall of the meatus. 

As the result of caries, the superior wall of the meatus 
close to the tympanum may be destroyed, bringing into view 
a portion of the head of the malleus and the adjacent part of 
the incus, or, where the ossicles have been destroyed or 
displaced, the upper part of the inner tympanic wall lies ex- 
posed. We then see distinctly the pelvis ovalis, and just 
above this the wall of the aquasductus Fallopii arching over 
it. If this last structure has been involved in the carious 
process, impact of the probe may cause twitching of the 
facial muscles, owing to mechanical irritation of the seventh 
nerve. 

Naturally, in inspecting the tympanic cavity where the 
membrana tympani has been destroyed as the result of dis. 
ease, or where a flap has been reflected for the purpose of 
exploration, the parts which can be brought into view will 
largely depend both upon the position in which the head of 
the patient is placed and upon the correct manipulation of the 
speculum, so that areas hidden from the direct line of vision 
Lof C. 



IOO PHYSICAL EXAMINATION. 

by the overhanging margins of the inner extremity of the 
canal may be illuminated by rays from the head mirror. 

Botey * has advised the use of small mirrors, which are to 
be introduced into the tympanic cavity for the purpose of in- 
specting the parts lying beyond the direct line of vision ; but 
the procedure has met with little success. Blake f suggested 
the same method long ago, and made a practical application 
of it to determine the attachment of a growth springing from 
the inner extremity of the superior wall of the canal. 

In the preceding pages we have spoken of the physical 
characteristics revealed by ocular inspection. The reader is 
not to understand, however, that the eye alone is to be used ; 
a delicate probe is of great service in settling a doubtful 
appearance, and the value of its use can not be too strongly 
advocated. Where it seems unadvisable to use a metal in- 
strument for fear of injuring the delicate structures, a very 
satisfactory substitute is found in the use of what may be 
termed a cotton probe, constructed as follows : A small bit of 
cotton is wound tightly about the extremity of a delicate cot- 
ton holder (Fig. 41) in such a manner that the cotton shall 
project for about a quarter of an inch beyond the end of the 



Fig. 41. — Cotton holder. 

shaft, it being wound so tightly as to offer considerable resist- 
ance upon pressure, and constituting really a prolongation of 
the probe. This cotton tip can be bent at any desired angle, 
and is firm enough to retain its shape, and yet not so firm as to 
injure the delicate structures encountered. It is less disagree- 
able to the patient than a metallic instrument, while it is of 
equal service to the examiner. An instrument constructed in 
this manner can be introduced through a small perforation in 
the membrana tympani, or into a sinus in front of or behind the 
short process, and be carried into the upper part of the cavity. 
Tactile impressions resulting from the proper manipulation of 
the instrument afford valuable information. 

The mobility of the membrana and ossicles should be de- 
termined as the next step of the examination. This may be 



- Rev. mens, de laryngol., vol. x, p. 681. 
f Trans. Am. Otol. Society, 1872. 



THE PNEUMATIC SPECULUM. IOI 

done by making use of Siegle's speculum (Fig. 42). It con- 
sists of a hard -rubber speculum, the wider extremity of 
which is screwed tightly into one end of a short cylinder of 
the same material as the speculum, while the extremity in- 
troduced into the canal is covered with a small bit of rubber 
tubing to effect an air-tight closure of the meatus. The op- 




Fig. 42. — Siegle's pneumatic speculum. 

posite end of the cylinder is closed by a cap which makes an 
angle of forty-five degrees with the axis of the instrument. 
In the centre of this cap is an opening covered with glass. 
Upon one side of this cylindrical chamber is an opening into 
which a short tube is screwed. The free extremity of the tube 
is connected with a small air pump, bellows, or atomizer bulb 
by a short piece of flexible-rubber tubing. 

After the speculum has been carefully inserted into the 
external auditory meatus, the air in the canal can be exhausted 
by means of the small air pump or rubber bulb with which 
the instrument is provided, or the flexible tube may be held 
between the lips and the air withdrawn in this manner. The 
density of the air in the meatus can be increased if desired by 
reversing the direction of the current. The glass in the outer 
extremity of the instrument permits the examiner to watch the 
different motions of the membrana tympani and ossicles, caused 
by the alternate condensation and rarefaction of the air in the 
canal. Were the glass at right angles to the axis of the 
speculum, the reflection of the illuminating ravs would inter- 
fere with the view of the deeper parts, but this is avoided if it 
is placed at an acute angle. Under normal conditions the drum 
membrane moves outward each time the air in the canal is 
rarefied, and passes in the opposite direction when condensa- 
tion is effected, the motion being most evident in the postero- 



102 PHYSICAL EXAMINATION. 

superior quadrant. The malleus at the same time rotates 
about the axis band, the short process remaining almost im- 
movable, while the long process participates in the outward 
excursion of the membrane. Areas over which the membrane 
is adherent to the inner tympanic wall are easily recognized, 
since they are not affected by changes in the air pressure. It 
is also important to note closely the motion of the malleus, for 
if bound down at its tip any outward excursion is impossible. 
Under these circumstances it either remains fixed, the mem- 
brane bulging beyond it in front and behind, when the air is 
exhausted, or it may move slightly outward at its upper part 
when there is relaxation of the structures in this tocality. 
Sometimes intratympanic adhesions fix the malleus in such a 
manner that, instead of rotating about the axis band, it rotates 
upon its long axis. This is frequently observed in cases where 
the entire ossicular chain and the membrana are drawn inward 
as a whole by adhesions, the membrane, therefore, giving no 
marked evidence of malposition except that it appears farther 
from the entrance of the meatus than usual. When the ex- 
cursions of the malleus are changed in character, so that rota- 
tion takes place about the long axis of the ossicle, we are 
warranted in assuming the presence of extensive intratym- 
panic adhesions, together with some relaxation at the malleo- 
incudal articulation. 

The use of a magnifying lens in connection with the pneu- 
matic speculum is seldom of advantage, the unaided eye dis- 
tinguishing variations from the normal quite as readily as 
when a lens is used. 

Our physical examination has thus far been confined to 
those parts of the conducting mechanism which can be inves- 
tigated by sight and by touch. We now have to call to our 
aid the sense of hearing for the examination of parts not ac- 
cessible to ocular inspection. These parts are the Eustachian 
tube and the tympanic cavity. 

Inflation of the Tympanum. — Since the tympanum com- 
municates with the pharyngeal vault through the Eustachian 
tube, a sudden condensation of air in the vault of the pharynx 
will cause a corresponding increase in air pressure in the mid- 
dle ear, provided the Eustachian tube is open. The tym- 
panum is separated from the external meatus only by the thin 
membrana tympani, and the examiner, by inserting a flexible 
tube into the meatus of the patient while the other extremity 



INFLATION OF THE TYMPANUM. 



103 



is inserted into his own auditory canal, is able to recognize 
the moment when the air enters the tympanum, by its impact 
upon this delicate partition. The sound produced under nor- 
mal conditions when the tympanum is suddenly inflated we 
may denominate, for convenience, the sound of impact. It 
is of sharp, metallic character, and is due to the stretching 
of the membrana tympani by the sudden condensation of 
the air within the middle ear. This sound seems to originate 
in the ear of the observer on account of the extreme thinness 
of the interposed partition, and the direct conveyance of the 
sound waves to his ear. Under normal conditions but a 
single sharp metallic click or snap is heard. This may be 
followed later by a similar sound of lower pitch and of less 
intensity, due to the return of the membrana to a condition 
of equilibrium in virtue of its elasticity. A familiarity with 
these signs in health enables the observer to interpret cor- 
rectly the significance of any modification in their character 




Fig. 43. — Auscultation tube. 

due to pathological conditions. It is sometimes stated that 
auscultation is a procedure of little diagnostic value, but I can 
only say that the otologist who would take this ground, might 
be compared with a physician who would consider himself 
able to judge of intrathoracic conditions without availing 
himself of auscultation of the chest. Auscultation certainly 
affords us a valuable means of recognizing certain conditions 
within the tympanum and Eustachian tube, if practiced suffi- 
ciently long to enable one to interpret the significance of the 
various sounds heard. 

Methods of Inflation. — The earliest method of inflation of 
the middle ear is that which bears the name of its discoverer, 
Valsalva. It is executed by the patient compressing the ala" 1 
nasi between the thumb and finger of one hand, thus closing 
the nostrils; at the same time the mouth is closed and the at- 



104 



PHYSICAL EXAMINATION. 



tempt is made to force air through the nostrils — in other words,, 
to blow the nose. The result is that the air is forced into the 
tympanum, since all other avenues of exit are closed. The 
procedure is frequently valuable as a diagnostic measure, as 
the surgeon can observe the effect of the increased intratym- 
panic pressure upon the drum membrane, by an inspection of 
the part while the patient performs the inflation. Depending 
as it does upon the patient himself for its efficiency, this pro- 
cess possesses but little therapeutic value. 

The most universally employed method of inflating the 
middle ear is that first brought into prominence by Politzer,* 

and bearing his name. To 
force air through the Eusta- 
chian tube by this procedure, 
the surgeon makes use of a 
balloon-shaped rubber bulb, to 
which a tube of the same ma- 
terial is attached ; the sudden 
compression of the bulb by the 
hand, expels the air through 
the free end of the tube with 
considerable force. This ex- 
tremity of the tube is provid- 
ed with a hard-rubber tip, so 
shaped that it may be inserted 
into the nostril of the patient, 
or in some instances it is coni- 
cal in form so as to occlude 
the nostril. In inflating with 
this instrument, the nose piece is held in position by the fin- 
gers of the surgeon's left hand, the other nostril being oc- 
cluded at the same time by compressing the alas of both sides ; 
the patient is then directed to take a small quantity of water 
into the mouth, and to swallow it at a given signal. Coinci- 
dent with the act of deglutition the physician compresses the 
bulb, which he holds in the right hand, by quickly and firmly 
closing the fingers upon it, thus driving the air within it into 
the pharyngeal vault, and from thence into the tympanic cavi- 
ties through the Eustachian tubes. The action of swallowing 
shuts off the pharyngeal vault completely from the oro-phar- 




Fig. 44. — Politzer's air-bag. 



* Wien. med. Woch., 1863, No. 6. 



POLITZERIZATION. 



105 



ynx, by the elevation of the soft palate, the muscular action 
effecting- this, at the same time serving- to render the tube 
more permeable, in the manner already described in consider- 
ing the function of the tubal muscles. Various modifications 
of this procedure have been devised, the success depending 
largely upon the intelligent co-operation of the patient. The 
act of swallowing must be coincident with the compres- 
sion of the inflating bulb ; otherwise, the naso-pharyngeal 
space will not be shut off, and an imperfect operation will be 
the result. When this occurs, the operator not only fails to 
carry out the measure intended, but occasions great discom- 
fort to the patient, and occasionally to himself, for the sud- 
den entrance of the air into the oro-pharynx forces the water 
which the patient is attempting to swallow, either into the 
larynx, bringing on a severe seizure of coughing, or out of his 
mouth, deluging himself and operator as well. 

The modifications of the Politzer method have been de- 
signed to obviate such accidents. One of the best is to direct 
the patient to close his lips and then puff out the cheeks, as 
though trying to whistle with the mouth closed. Another 
fairly successful method is to repeat rapidly the letter K, or 
any syllable containing the K sound. Either of these proced- 
ures, causing an elevation of the soft palate, effects a fairly 
perfect closure of the pharyngeal vault. These modifications 
are of particular convenience in children, and render the oper- 
ation much less uncomfortable. In infants the act of crying 
produces sufficient closure of the naso-pharygneal space to 
allow of a successful inflation of the middle ear, if the air bag 
is forcibly compressed while the child is crying. 

There can be no question of the value of Politzer's method 
both as a diagnostic and therapeutic procedure, but its use 
should, I think, be restricted to certain cases, and it should 
not be adopted to the exclusion of catheterization of the tube. 

A few words will not be out of place here regarding the 
selection of a proper inflating bulb, or Politzer bag, and of a 
proper tip for the instrument. The error usually made is to 
choose an unnecessarily large bag. A large instrument is 
cumbersome and at the same time less efficient, since it can 
not be so grasped that the hand is able to compress it quickly. 
The lumen of the delivery tube is frequently so small in pro- 
portion to the size of the bag, that when a sudden effort at 
compression is made, very little air is forced out, the ten- 



io 6 PHYSICAL EXAMINATION. 

sion in the bulb almost immediately reaching such a degree 
that further compression is impossible. The use of a small 
bulb, of not more than four ounces' capacity, is attended with 
more satisfactory results ; the instrument can be easily held 
in the palm of the hand, so that the fingers encircle it, and 
can be almost completely emptied when the hand is quickly 
closed upon it. The actual air pressure obtainable with a 
bulb of moderate size is greater than with one of large di- 
mensions. It is immaterial whether the air bag is provided 
with a valve which allows the entrance of air, but closes when 
the bulb is compressed, or whether it has but a single open- 
ing, in which case the free end must be removed from the 
nostril after each act of inflation. When this last form of bag 
is employed it must be removed from the nostril before the 
pressure upon the bag is relaxed ; otherwise, the mucus from 
the nasal cavity will be sucked up into the tube. To prevent 
this accident it is also important that the tip be wiped imme- 
diately after removal, either with cotton or with a towel, and 
before allowing the bag to refill. It is more convenient cer- 
tainly to use a bag provided with a valve, although even here, 
if the nose piece is allowed to remain in position, a certain 
amount of mucus may be aspirated from the nasal cavity. 
The objection to the valve lies in the fact that it is liable to 
get out of order. This difficulty may be obviated by cutting 
a hole in the side of the ordinary bag, and covering the open- 
ing with the hand during the act of compression ; as the fin- 
gers are relaxed it is uncovered, thus allowing the balloon to 
fill readily. This is certainly more simple than any automatic 
valve, and demands only a little attention on the part of the 
operator to see that perfect closure of the opening is effected 
at each act of inflation. Personally, I often use a very small 
bulb of a capacity of about two ounces, such as is supplied 
with the ordinary hand-ball nasal atomizer. The valves in 
these instruments are fairly w r ell made, and do not get out of 
order readily. The one which I prefer has two valves, one 
allowing the air to enter at the distal end of the bulb, while 
at the same time a valve at the opposite extremity closes the 
channel between the bulb and the nasal cavity of the patient, 
preventing the entrance of mucus. This small bulb is also 
particularly adapted for use with the catheter, it being only 
necessary to change the tip. 

Regarding the particular form of tip suitable for insertion 



CATHETERIZATION. 107 

into the nostril, individual preference will probably be the 
best guide. Many advocate the use of a small, curved hard- 
rubber tip. This tube is inserted into the inferior meatus, 
where it is held between the fingers and thumb of the left hand, 
which at the same time compress the alas nasi so tightly as to 
allow no air to escape. I have never been able to use this in- 
strument to my own satisfaction, although there is no question 
that it is perfectly efficient in other hands. The objection to 
its use is that the introduction of the tube into the nostril may 
be painful, if the septum is considerably deflected, and even 
when the greatest care is used, slight haemorrhage may follow 
the procedure. If this form of tip is chosen, care should be 
taken that its calibre is ample, permitting a large volume of 
air to pass through it. As the instrument is usually sold in 
the shops, the bore is very small in comparison with the ex- 
ternal diameter of the tube. It is also wise to cover the end 
of the tube to be introduced into the inferior meatus with 
a piece of thin rubber tubing, as an abrasion of the nasal mu- 
cous membrane is less liable to be caused if this is done. 

For my own use I prefer a conical tip, which occludes 
the anterior nasal opening perfectly by the coaptation of its 
surface with the soft walls of the opening into which it is in- 
serted. This conical tip may be constructed either of glass, 
hard rubber, or aluminium, and care should be taken that the 
opening through it is of sufficient size to allow a free passage 
of the air when sudden condensation is effected. In children 
this conical tip is unquestionably more effectual and more 
easily manipulated than the one previously mentioned. 

Catheterization of the Eustachian Tube. — By this manipu- 
lation the surgeon directs a current of air into the tympanum 
of one side or the other, by means of a canula, which is passed 
through the nasal passages into the vault of the pharynx and 
inserted directly into the Eustachian orifice. 

Before giving a detailed description of the method of intro- 
ducing the instrument, a few words may be said concerning 
the catheter itself (Fig. 

45). It consists of a tube ^gg ' " ' bsb-b=— JlMilgfl 

of either hard rubber, w ® © (o) © ^ 

pure Or coin silver, or FlG> 45 ._ T he Eustachian catheter. 

of German silver, about 

eight inches long, bent in the arc of a circle at one extremity. 

while at the other it is expanded into an elongated funnel, 



I0 8 PHYSICAL EXAMINATION. 

which constitutes about an inch of its length. The canulse 
vary in external diameter from No. 3 to No. 6 of the French 
scale. The expanded end of the catheter is provided with a 
guide ring, fastened to that wall of the tube corresponding to 
the concavity of the arc described by the pharyngeal extrem- 
ity, for the purpose of informing the observer of the position 
of the beak of the instrument when in the nasal cavity. De- 
cided preference should be given to the pure silver instru- 
ments, since the curve can be easily changed to meet the 
necessity of any individual case. German silver possesses too 
little flexibility to permit of the instruments being easily bent, 
while the hard-rubber instruments, although they can be molded 
into any form, after they have been heated, usually possess so 
small a lumen in comparison with the external diameter of the 
tube, as to render them unfit for use. Even in the pure silver 
instruments this objection occasionally exists, the walls being 
unnecessarily thick, and attention should be directed to this 
point in selecting the catheter. Care should also be taken that 
the margin of the lumen of the pharyngeal extremity is smooth, 
so as not to abrade the mucous membrane with which it comes 
in contact. Hartmann * advises that the tip shall be slightly 
bulb-shaped for this reason. This is not necessary if care is 
taken that the margins of the opening are slightly inverted, 
making the periphery perfectly smooth. As to the proper 
size of catheter, it is ordinarily stated that the largest instru- 
ment which can be introduced through the nasal passages 
should be employed, and in some instances an instrument of 
large calibre is of service. It should be remembered that the 
width of the isthmus of the tube is never greater than one 
tenth of an inch, and usually its diameter is less than this ; 
therefore there can be no advantage in using a catheter 
whose calibre is many times greater than this. If the tube is 
obstructed, a small instrument is even more efficient, since the 
column of air will exert a greater pressure than when a large 
instrument is used. Any advantage gained by an instrument 
of large size is, I think, more than counterbalanced by the in- 
creased delicacy of manipulation which the smaller allows, 
enabling the operator to locate it more exactly. Regarding 
the proper curve of the instruments, this must of necessity 
vary in different cases, according to the width of the pharyn- 

* Krank. des Ohres, Berlin, 1889, p. 44. 



CATHETERIZATION. 



109 



geal vault, the prominence of the tubal orifices, and the irregu- 
larities met with in the nasal chambers. 

Buck* advises that the curve of the catheter be long and 
gradual, and finds this form adapted to a greater number of 
cases than one in which the radius of the arc is shorter. This 
shape is especially valuable where the inferior meatus is ob- 
structed by a ridge located rather low down on the septum. 
Many times a sharper curve, such as advocated by Urbant- 
schitsch,f will be found to give a more perfect inflation. 
Herein lies the advantage of the pure-silver instrument, since 
it can be molded easily into any desired form, according to 
the demands of each case. It is of some importance that the 
catheter shall not be so long that when in position it projects 
more than an inch and a quarter beyond the nasal opening. 
It is more difficult to maintain the instrument in a fixed posi- 
tion if it projects farther than this, since any slight motion 
serves to displace it from the tubal orifice. When the project- 
ing portion is short very little leverage can be obtained, and 
there is less possibility of inflicting injury upon the delicate 
structures encountered, in the event of rough manipulation. 

The particular device to be used for effecting inflation 
has been discussed thoroughly, each form having its advo- 
cates. The ordinary Politzer bag is most commonly em- 
ployed, the delivery tube terminating in a conical tip which 
fits into the outer end of the catheter exactly ; or, in some 
instances, the tip is larger than the mouth of the catheter, the 
bag being so held at the moment of compression that the tube 
is applied as closely as possible to the mouth of the cathe- 
ter, but not fitting into it tightly, thus preventing undue pres- 
sure at the moment of condensation of the air. When a valve- 
less air bag is used in this manner it must be removed after 
each act of compression to allow it to refill, and the repeated 
adjustment to the lumen of the catheter can not but disturb 
the position of the instrument, and be a source of discomfort to 
the patient. It is much simpler to make use of the ordinary 
atomizer bulb, provided with a valve at either extremity and 
connected with the catheter by a piece of rubber tubing 
about twelve inches long. The delivery tube is joined to the 
catheter through the interposition of a conical tube ground 
to fit the catheter exactly ; this allows a free manipulation of 

* Op. cit. f Lehrb. der Ohren., Wien, 1S90. p. S. 



HO PHYSICAL EXAMINATION. 

the bulb, without any motion being imparted to the catheter 
when it is once in position. When this apparatus is used the 
hard-rubber tube is fitted into the catheter before the instru- 
ment is introduced into the nose, the small size of bulb ren- 
dering it possible to grasp this in the palm of the hand, while 
the fingers of the same hand hold the catheter and manipulate 
it during its passage through the nasal cavity (Figs. 46 and 
47). This allows of great freedom of manipulation, on account 
of the length of the tube which joins the catheter to the bulb. 
After the catheter is once in place the fingers of the left hand 
fix it, while with the right hand the surgeon compresses the 
bulb as many times as may be necessary. No motion is com- 
municated to the instrument as the bulb is emptied, and no 
discomfort attends the operation. Certainly from a humane 
point of view this method is to be preferred ; and it may also 
be said that since the mechanical irritation is reduced to a 
minimum the therapeutic value is also greater. 

Lucae * advises the interposition of an elastic bulb be- 
tween the inflating bag and the catheter to serve as a re- 
ceiver, which is filled by the compression of the inflating bag. 
The elasticity of this second bulb permits of the introduction 
of a continuous current of air into the tympanum. It has 
never in my experience seemed necessary that the current of 
air should be continuous, and for diagnostic purposes cer- 
tainly, it would be of less value than an intermittent current. 

Many Continental otologists advocate the use of a higher 
air pressure than can be obtained by any of the above instru- 
ments, and employ some form of air pump to secure the 
proper amount of tension. In such an instrument the air is 
forced by the pump into a large receiver, provided with a 
gauge for registering the degree of condensation. The 
Eustachian catheter is connected with this receiver by means 
of a flexible tube, and the air is allowed to escape through 
the instrument by means of a properly adjusted cut-off. 

When the Eustachian tube is so much obstructed that 
catheter inflation is impossible with the ordinary air bag, some 
method should be employed to determine the exact nature of 
the obstruction, rather than to attempt to perform inflation 
with very high air pressure. The same remark will apply to 
the use of any form of foot bellows for a similar purpose. Re- 

* Archiv flir Ohrenheilk., vol. ii, p. 308. 



CATHETERIZATION. 



Ill 



garding all of these devices, it should be borne in mind that, 
as a diagnostic measure, considerable information is gained 
by estimating the amount of force necessary to empty the 
bag by compressing it in the palm, in order to secure a free 
entrance of air into the tympanum, as evidenced by auscul- 
tatory signs. The hand and ear of the operator then act 
together, allowing him to interpret the relation between the 
intensity of any particular sound heard, and the force neces- 
sary to secure the degree of pressure requisite to force the 
air into the tympanum and produce the sound. 

An appropriate catheter and inflating apparatus having 
been selected, the next step is the technique of inserting the 
instrument. The plan which seems most simple will be first 
described, after which other methods will be detailed. 

The inflating bulb is held in the palm of the right hand, 
while the catheter, having been properly connected with it, is 
grasped lightly between the thumb and index and middle fin- 
gers of this hand, much as 
a pen is held. The shaft 
of the instrument points 





Fig. 46. — Introduction of the Eus- 
tachian catheter (first step). 



Fig. 47. — Introduction of the Eus- 
tachian catheter (second step). 



directly upward, while the curved pharyngeal portion lies 
in the horizontal plane, the orifice of the catheter looking 
forward. The patient should be seated in a chair with a 
high back, and the head should be inclined forward slightly, 
while at the same time he should be directed to close the lips 
tightly and breathe slowly and quietly through the nostrils. 
The operator, either standing or sitting at the right of the pa- 



112 



PHYSICAL EXAMINATION. 



tient, tilts the tip of the patient's nose upward with the ball 
of the left thumb, the index and middle ringers resting upon 
the nose just below the bridge. From this moment the left 
hand is not removed from the patient's nose until inflation has 
been accomplished and the catheter has been removed. The 
tip of the nose being elevated, the extremity of the catheter is 
introduced into the nostril ^see Fig. 46) ; as soon as the instru- 
ment has passed the slight ridge at the nasal orifice the opera- 
tor carries the hand holding the instrument upward until the 
catheter assumes a horizontal position. In this position, with 
the tip kept constantly upon the floor of the nasal cavity, the 
catheter is .passed directly backward through the inferior 
meatus until the posterior pharyngeal wall is encountered 
(Fig, 4y) ; it is then drawn forward about three eighths or one 
fourth of an inch, and. remembering that the guide ring on 
the shaft indicates the direction in which the pharyngeal ex- 
tremity points, the instrument is rotated upon its long axis 
until the ring points almost directlv outward toward the side 
to be inflated. The hand is then elevated a little and carried 
slightly toward the opposite ear, causing the pharyngeal ex- 
tremity of the instrument to descend, and at the same time to 
press lightly against the lateral pharyngeal wall. By drawing 
the catheter a little outward, the tip will be felt to impinge 

upon the posterior lip of the tube ; it 
is to be drawn over this, the tip being 
turned slightly downward, if neces- 
sary, to effect this without undue 
force. As soon as the operator knows 
by the sense of touch that the promi- 
nent posterior lip has been passed, the 
catheter is rotated upon its long axis 
until the guide ring points upward 
and outward toward the ear, while at 
the same time the outer extremity of 
the instrument is moved toward the 
opposite side, thus pushing the pharyn- 
geal extremity well into the mouth of the tube. When care- 
fully placed, the sense of fixation imparted to the hand is un- 
mistakable. At this juncture the left thumb is moved so as 
to pass beneath the catheter and support it. The instrument 
is thus held firmly against the margin of the nostril, by the 
thumb below and the first three fingers, resting upon the 




Fig. 48. — Introduction of the 
Eustachian catheter (the in- 
strument fixed in the mouth 
of the tube). 



AUSCULTATORY SOUNDS. 



113 



bridge of the nose, above (Fig. 48) ; at the same time the tip of 
the nose is pressed upward as before. The right hand is now 
free to compress the bulb, forcing the air through the catheter 
into the middle ear, its entrance being recognized by sounds 
heard through the auscultation tube. 

As already stated, the value of auscultation for diagnostic 
purposes can not be overestimated, and the catheter is much 
superior to other methods of inflation when the operation is 
performed as a diagnostic measure only. The amount of 
manual pressure necessary to force the air into the tympanum 
is also of importance in determining the degree of obstruction 
present, and this may be roughly estimated by the operator 
with each act of compressing the bulb. The various sounds 
produced afford exact information as to the physical condi- 
tion of the mouth of the tube, of the tubal canal, and of the 
tympanum. These advantages are not offered by the Politzer 
method of inflation, since the efficiency of the procedure de- 
pends entirely upon the ability of the patient to close the 
naso-pharyngeal space completely at the proper moment. In 
catheterization the operator has the entire control of the pro- 
cedure, and from knowledge derived by the sense of touch as 
to the exact location of the catheter, and by an estimate of 
the force employed during the act of inflation, he is able to 
derive valuable information from the various auscultatory 
sounds elicited during the experiment. 

Auscultatory Sounds. — We may consider that the sounds 
heard through the auscultation tube are produced either at 
the pharyngeal orifice of the tube, or within the lumen of the 
canal, or within the tympanum. Frequently the ear analyzes 
the impression made upon it during such an examination, re- 
solving the combination of sounds heard, into the several sim- 
ple sounds produced at each of these locations. 

The determination of the point at which a given sound is 
generated consists in measuring its intensity or its proximity 
to the ear of the examiner. Since the tympanum of the pa- 
tient is separated from the lumen of the diagnosis tube simply 
by the drum membrane, any sound produced by the air 
entering the tympanum will appear to originate in the ear of 
the examiner. We also remember that, on entering the tym- 
panum, the current passes from a narrow canal into a cavity 
of comparatively large size, and we should expect that its 
character would be modified by this change in the physical 



14 



PHYSICAL EXAMINATION. 



conditions, so that the pitch would be lowered and the qual- 
ity softened. 

On the other hand, sounds originating in the Eustachian 
canal would be of higher pitch, but would impress the listener 
as though they came from a greater distance from his ear 
than the tympanic sounds. Auscultation sounds originating 
in the naso-pharynx or at the pharyngeal orifice of the tube 
will seem still more distant, being heard quite as well with 
the open ear as through the auscultation tube. 

The Normal Tympanic Bruit. — With the parts in a normal 
condition the surgeon hears with each compression of the 
bulb of the inflating apparatus a soft, dry, blowing sound, 
together with a slight but distinct percussion sound due to 
the impact of the current of air upon the drum membrane. 
This last is compared by Deleau * to drops of rain as they 
fall upon foliage in the forest during a shower. The " blow- 
ing sound " is produced by the passage of the aerial current 
through the catheter and Eustachian tube into the cavity 
of the tympanum; the " impact sound," by the obstruction 
offered by the membrana tympani to the farther progress of 
the air. With the membrane in a proper position and under 
normal tension, this last sound is but slightly marked, and 
may be so indistinct as to be entirely overlooked. It is 
possible, however, with care, to make out the tympanic, tu- 
bal, and pharyngeal components of the auscultation sound in 
almost every instance. We have next to examine the vari- 
ations which the normal auscultation sound undergoes when 
the various parts are not in a condition of health. We will 
consider these according to the special region in which they 
arise. 

i. Tympanic Sounds. — (a) An exaggeration of the "impact 
sound " indicates a considerable displacement outward of the 
membrane under the influence of the increased tympanic pres- 
sure. Hence the membrane must have been retracted, oc- 
cupying an abnormal position — a fact already determined by 
previous speculum examination ; or, if occupying a normal 
position, it must have been so relaxed as to admit of consid- 
erable outward displacement by the aerial condensation. If 
this last condition exists a secondary sound will be heard, as 
the hand holding the bulb relaxes, thus allowing the pressure 

* Acad, de Sci., Dec. 7, 1829. 



TYMPANIC SOUNDS. 115 

in the middle ear to diminish, by the escape of the air from 
the tympanum through the tube into the pharyngeal vault. 
The amount of air forced backward in this way, and conse- 
quently the intensity of this secondary sound, will depend 
upon the resiliency of the membrana tympani and the exact- 
ness with which the catheter fits the pharyngeal orifice. This 
secondary sound is sharp and similar to the original " impact 
sound," but less intense. 

Sounds having their origin within the tympanum are 
heard so distinctly that those not accustomed to the use of 
the auscultation tube will frequently describe them as origi- 
nating within their own ear. 

{b) If now the tympanic cavity is filled with fluid the nor- 
mal " blowing " and " impact " sounds undergo a change, so 
that a rough bruit is observed in place of the " blowing 
sound," accompanied and followed by a series of sharp crack- 
ling rales following each other at irregular intervals, and 
persisting for a short period as the inflating bulb is allowed 
to refill. This rattling appears to be in the ear of the exam- 
iner, and conveys the impression of a current of air being 
driven through a collection of fluid. The quality of these 
rales gives some hint as to the nature of the fluid. Crepita- 
tation of a fine, high-pitched character is heard when the fluid 
is watery, but the rales are coarse, low-pitched, and bubbling 
when the liquid is thick and viscid and adheres to the walls 
of the cavity. These distinctions are of but little importance, 
as the exact nature of the fluid is of no moment. It must also 
be remembered that even if fluid is present, it may lie out 
of the course of the current of air which enters the cav- 
ity, and the auscultation sound may afford no evidence of its 
presence. 

(c) When the cavity of the tympanum is completely filled 
with fluid no crepitation is heard, as the air fails to enter the 
middle ear at all, and the normal " blowing sound " is also 
wanting. The "impact sound," however, is heard as the 
current of air enters the tube and impinges upon the fluid 
contained in the tympanum. The percussion sound, how- 
ever, loses its sharp character, appearing indistinct, distant, 
and low-pitched. 

(d) Any solution of continuity in the drum membrane is 
easily discovered upon forcing air through the Eustachian 
tube, provided the opening through the membrana is not 



Il6 PHYSICAL EXAMINATION. 

completely shut off from the Eustachian canal by adhesions. 
The character varies with the size of the opening, being 
high-pitched and whistling when this is small, and of a blow- 
ing quality when the area destroyed is greater. With exten- 
sive destruction of the membrana the air is felt to enter the 
canal of the examiner and to impinge upon the walls of the 
meatus. The pitch of the note heard when the perforation 
is of moderate size will depend somewhat upon the thickness 
of its edges. Where the drum membrane is greatly swollen 
the edges do not vibrate freely and the sound is rather low- 
pitched. Where the thickening is not excessive, and espe- 
ciallv if the membrane is fairly tense, a high-pitched note, 
known as the "perforation whistle," is heard. 

(e) Certain sounds comparable to those heard when two 
moist surfaces are forcibly separated are frequently per- 
ceived upon inflation, and, from their apparent proximity to 
the ear of the examiner, evidently originate within the tym- 
panic cavity. They are caused by the separation of the 
membrana from the inner tympanic wall, by the act of infla- 
tion, and are met with in cases where slight hypersecretion 
has taken place, allowing the two opposing surfaces to adhere. 
Occasionally these signs indicate the rupture of newly formed 
adhesions. 

(/) When the middle ear is the seat of adhesive inflam- 
mation, which diminishes the size of the cavity bv drawing 
the drum membrane inward, or when this structure itself is 
thickened and rigid from connective-tissue hyperplasia or 
from calcareous deposits, or where the tympanic orifice of 
the tube has been greatly narrowed, the tympanic factor of 
the bruit is practically lost, and the sound seems distant. 
This is observed most frequently in patients of advanced years. 

2. Tubal Sounds. — In passing through the Eustachian canal 
the column of air is thrown into vibration, producing sounds 
which vary in character according to the patency of the pas- 
sage, the condition of the walls, and the presence or absence 
of moisture. When the air is not heard to enter the tym- 
panum, but the listener is conscious of a distant harsh blowing 
sound with each act of inflation, the catheter being correctlv 
placed, but one interpretation can be made of the sign — it 
must indicate stenosis of the channel. The location of the ob- 
struction is determined by observing the relative distance at 
which the sound appears to be from the ear of the examiner. 



TUBAL SOUNDS. 



Ii; 



It approximates more nearly to the pure pharyngeal sound 
according as the barrier is located nearer this orifice. When 
the bruit is fairly constant in quality and intensity, the nar- 
rowing may be looked upon as depending upon some organic 
change in the tubal walls. 

On the other hand, if its character changes with each act 
of compression of the air bag, then it is probable that the 
lumen of the tube is closed either by a plug of secretion or by 
tumefaction of the lining membrane. In the first instance the 
listener hears a harsh, moist, rasping sound, the pitch of which 
varies each time the air is forced inward, while occasionally 
the current will be heard to rush into the middle ear. This 
is caused by the momentary displacement of a mass of tena- 
cious mucus which occludes the channel, permitting the air 
to enter. Prolonged inflation usually dislodges the obstruc- 
tion and allows the current to enter the tympanum with each 
compression of the bulb. 

When the tube is narrowed in calibre at any point by 
slight swelling or by a hyperplastic process, the blowing 
sound is of higher pitch, according to the degree to which 
the channel is narrowed, being of the squeaking or whistling 
character when the stenosis is nearly complete. When due to 
a hyperplastic process the sound varies but little as inflation 
continues, while if it depends simply upon swelling of the 
walls of the passage, the mucous membrane being at the same 
time moist, the bruit changes considerably in quality as the 
operation is continued, moist, crackling, or snapping sounds 
being heard from time to time, which modify the high-pitched, 
whistling note. The sensation of proximity to the observer is 
wanting, and this fact indicates the tubal origin. 

When the walls of the tube are in contact, as the result of 
oedema, the air frequently fails to enter the passage when an 
attempt is made to compress the bulb, the catheter, if properly 
located, seeming to be completely occluded. A slight move- 
ment of the instrument and repeated efforts at inflation pro- 
duces a distant clicking noise, followed by a high-pitched 
whistle, and the air is felt to rush into the middle ear sudden- 
ly. This phenomenon repeats itself during the operation, the 
air entering the tympanum only after the bulb has been com- 
pressed several times, and then but in small quantity. 

It is scarcely necessary to call attention to the signs ob- 
served where the tube is abnormally patent ; one need only 



H8 PHYSICAL EXAMINATION. 

remember that the intensity of the tympanic sound must be 
greater if the tube is of wide calibre than if it is narrowed. 
The same is true of the intensity of the tubal sound itself. At 
the same time there will be no resistance to compression of 
the bulb. 

3. Pharyngeal Sounds. — These sounds are easily recognized 
by their variable character ; they are heard also quite as well 
through the air as through the diagnosis tube. Even when a 
perfect inflation is made under normal conditions a soft, indis- 
tinct blowing sound, depending upon the escape of a certain 
amount of air into the pharyngeal vault, is heard with the open 
ear. With partial or complete occlusion of the Eustachian 
canal, or when its pharyngeal orifice is filled with secretion, 
this sound becomes louder, and, if the trumpet-shaped orifice 
of the tube contains viscid mucus, is of a hoarse, rasping qual- 
ity as the air bubbles through it. While these sounds may be 
heard even when the instrument is correctly placed if the 
parts are swollen and inflamed, still they most frequently in- 
dicate that the catheter has been improperly manipulated, and 
that the tip lies in Rosenmuller's fossa, behind the tubal ori- 
fice. Occasionally the catheter is pressed so forcibly against 
the lateral wall of the - pharynx as to completely occlude the 
lumen, and no air can be forced through the instrument upon 
attempting to perform inflation. A forcible effort at infla- 
tion may partially overcome the resistance, giving rise to a 
harsh, rasping sound as the current passes from the instrument 
and overcomes the elasticity of the mucous membrane which 
has occluded the opening. Sometimes, instead of lying ex- 
actly in the pharyngeal orifice, the instrument impinges upon 
the posterior lip of the tube. The pharyngeal bruit will pre- 
dominate if this is the case, and will be of a particularly dis- 
cordant, vibratory character, the cartilaginous plate forming 
the posterior wall of the tube being thrown into irregular vi- 
brations each time the bag is emptied. 

While the preceding description of these sounds may seem 
complicated, their recognition is simple after a little practice, 
and it is easy to recognize any undue prominence of the tubal, 
tympanic, or pharyngeal factors of the bruit. The informa- 
tion gained by close attention to this method of examination 
will amply repay one for the labor expended in perfecting him- 
self in it. 

But one 4 method of introducing the catheter has been given 



METHODS OF CATHETERIZATION. 



II 9 



as yet, for the reason that it has seemed better to take this one 
as the standard, and to describe the variations in technique 
which may be resorted to when this first method, for any rea- 
son, is not successful. It is advisable for the beginner to ad- 
here closelv to one method of catheterization rather than to re- 




Fig. 49. — Vertical section through nasal chambers and pharyngeal vault of adult. 
The lower portion of the septum, opposite the inferior turbinated body and the 
inferior meatus, has been removed, exposing the course followed by the cathe- 
ter. The Eustachian orifice is well marked. (Author's specimen.) 

sort to several as soon as difficulties arise, it being more easy 
to become expert in the manipulation by the constant use of 
one method. 

Loewenberg * modifies the technique in the following man- 
ner : When the pharyngeal extremity of the catheter is felt to 
impinge upon the posterior wall of the naso-pharynx the in- 



* Arch, fur Ohrenheilk., vol. ii, p. 12. 



120 



PHYSICAL EXAMINATION. 



strument is rotated upon its long axis so that the guide ring 
shall be directed toward the opposite ear; the catheter is 
then drawn forward until its concavity is felt to engage the 
posterior margin of the nasal septum ; it is then rotated 
downward through an angle of one hundred and eighty 
degrees, until the guide points toward the ear to be inflated, 
while at the same time the catheter is carried toward this 
side. 

According to the writer quoted, when rotation has been 
completed, the beak of the instrument will be found to lie in 




Fig. 50. — A section made in the same manner as that shown in Fig. 49, showing the 
conformation of the parts in a child of five years. The pharyngeal vault is filled 
with adenoid vegetations, and the tubal orifice is less marked and lies farther 
forward than in the adult. (Author's specimen.) 

the mouth of the Eustachian channel. The prolonged manipu- 
lation is rather prone, in my experience, to cause a contraction 
of the muscles of the soft palate, and therefore constitutes a 
source of discomfort to the patient. The variations in the ex- 
act position of the tubal orifice and in the transverse diameter 
of the naso-pharynx, detract much from the special value of 
this method. The same technique had previously been advo- 
cated by Frank.* Boyer f prefers to rotate the instrument 



* Lehrb. der Ohren., 1845, p. 101. 

f Annal. des mal. de 1'oreille, 1877, vol. iii, p. 69. 



METHODS OF CATHETERlZATIOxM. 



121 




upon its long axis, as soon as the tip passes the choanae, as 
recognized by the diminished sensation of resistance to the 
entrance of the instrument, until its extremity points to the 
affected side. Its 
exact insertion into 
the tubal orifice is 
effected by pressing 
the beak outward 
toward the later- 
al pharyngeal wall. 
This method is oc- 
casionally of service 
when the parts are 
irritable, and the op- 
erator knows, from 
previous experience, 
the exact location of 
the tubal opening. 

Triquet* follows 
almost thesameplan, 
but rotates the cath- 
eter before it leaves the inferior meatus, so that it may be arrest- 
ed by the tubal prominence as it is pushed farther backward. 

Wolff f and Gruber J advise that after the instrument, 
with the pharyngeal extremity directed downward, has been 
passed through the inferior meatus until the pharyngeal wall 
is reached, it shall be drawn forward until it is arrested by 
the soft palate ; it is then advanced slightly toward the pos- 
terior pharyngeal wall, after which the angular portion is 
rotated toward the ear to be inflated, causing the extremity 
to enter the tubal mouth. 

Kramer # suggests that use be made of the reflex contrac- 
tion of the soft palate, which is excited by the presence of the 
catheter, to cause the instrument to assume its correct posi- 
tion in the tubal mouth. Having carried the catheter backward 
to the posterior wall of the naso-pharynx, it is drawn forward 
over the prominent posterior lip until it impinges upon the 
soft palate. This manipulation is followed bv a contraction 



Fig. 51. — A section through the nasal passages and 
naso-pharynx in an infant, showing the turbinated 
bodies and tubal orifice. The lips of the tube are 
poorly defined. A similar condition is frequently 
met with in advanced life. (Author's specimen.) 



* Traite pratique des mal. de l'oreille, 1857. 

f Lencke's Handb. der Ohrenheilk., vol. iii, p. 358. 
X Lehrb. der Ohrenheilk., Vienna, 1SS8, p. 203. 

# Ohrenkrankheit., 1836, p. 24S. 



122 ' PHYSICAL EXAMINATION. 

of the palatal muscles, which forces the instrument upward. 
At this instant it is quickly rotated toward the affected side, 
the contraction of the palate crowding it into the tubal orifice. 

It will be seen that in all of these methods, with the ex- 
ception of Frank's, the technique of introduction is but 
slightly modified from that first described, and that the facil- 
ity with which the operation can be performed will depend 
greatly upon the ability of the operator to recognize the 
yarious structures which the pharyngeal extremity impinges 
upon, after the instrument has entered the nasopharynx. 

Obstacles to Catheterization. — Certain difficulties depend- 
ing upon anatomical characteristics peculiar to any giyen 
case may be encountered in attempting to perform catheter- 
ization. The most frequent obstacle is a considerable de- 
formity of the septum narium, causing a partial occlusion 
of the inferior meatus. Since the introduction of cocaine, 
catheterization has become much more simple, as the ex- 
sanguination of the turbinated tissues increases the dimen- 
sions of the cavity materially, while at the same time, on 
account of its anaesthetic properties, prolonged manipula- 
tion is possible. Before attempting to introduce the Eus- 
tachian catheter, it is always wise to make a careful ante- 
rior rhinoscopic examination, to determine the presence and 
nature of any obstruction. If a considerable obstructiye 
lesion exists, the catheter may be introduced under direct 
inspection, the parts being illuminated by reflected light, 
and the eye directing the yarious movements of the instru- 
ment until it has entered the naso-pharynx. A ridge upon 
the septum, which extends horizontally toward the outer 
wall of the cavity, is perhaps the most perplexing condition 
found. The curve of the catheter must be such that it may 
traverse the inferior meatus beneath the obstructing ridge ; 
herein lies the advantage of a pure silver catheter, since 
it is a simple matter to change the curve of the instrument 
to suit the particular condition encountered in any case. 
It is not always possible to introduce the instrument with 
the curved extremity pointing downward, when a prominent 
ridge or excrescence presents anteriorly, and it is often ad- 
visable in such cases to turn the tip of the catheter to one or 
the other side, effecting its introduction into the cavity in the 
oblique diameter rather than in the vertical. Again, when 
there is a prominent ridge at the very entrance of the vesti- 



OBSTACLES TO CATHETERIZATION. 



123 



bule, and the passage beyond is obstructed as well, it may be 
necessary to enter the nasal cavity with the catheter so held 
that the concavity is directed upward, the convexity apply- 
ing itself to the depression just within the vestibule. In such 
a case, as soon as the naso-pharyngeal space is entered, the 
instrument should be rotated until it has assumed the proper 
position. This rotation should be made toward the unaf- 
fected side to avoid touching the lateral pharyngeal wall. 

It sometimes happens that the conformation of the parts 
will not allow the instrument to enter the inferior meatus, 
although the middle meatus may be capacious. In such an 
event, if the catheter is so bent as to increase the length of 
the angular portion, it is a simple matter to pass it through 
the middle meatus, above the obstruction, until the pharyn- 
geal wall is encountered ; after it has passed into the naso- 
pharynx the extremity of the instrument held in the fingers 
is elevated — a manipulation which will allow the long, angular 
part to engage in the tubal mouth upon rotation, although 
the horizontal portion of the instrument lies at a higher level 
than the entrance of the tube. Naturally, the greatest deli- 
cacy must be exercised in conducting this procedure, as from 
the increased length of the angular portion it will be easy to 
wound the delicate tissues of the naso-pharynx in rotating 
the instrument upon its long axis at the moment when the 
extremity is carried into the mouth of the tube. 

When one nasal passage is blocked so that the introduction 
of a catheter is impossible, it may be carried through the pas- 
sage of the opposite side, as advised by Deleau.* The curved 
portion of the catheter must be considerably longer than 
usual, and if the vault of the pharynx is unusually wide the 
procedure is not satisfactory, as a rule. The technique con- 
sists of carrying the instrument through the nasal passage of 
the opposite side, the free extremity resting upon and gliding 
along the floor of the inferior meatus. When the posterior 
pharyngeal wall is encountered the instrument is rotated so 
that the pharyngeal extremity points toward the ear to be in- 
flated. The catheter is made to enter the fossa of Rosennniller 
by carrying the extremity of the instrument held between the 
fingers away from the septum, until further motion is pre- 
vented by the lateral pharyngeal wall. The instrument is now 



* Rev. med., 1827. 



124 



PHYSICAL EXAMINATION. 



drawn outward for about one fourth of an inch, or until the 
prominent posterior lip of the tube is felt ; it is made to glide 

over this by drawing it outward, 
while at the same time the outer 
extremity of the instrument is ele- 
vated so as to allow the angular 
portion to pass over the posterior 
lip of the tube close to its lower 
margin ; the outer extremity of the 
instrument is then carried away 
from the side to be inflated — a ma- 
nipulation which forces the pharyn- 
geal end into the mouth of the Eus- 
tachian tube. This method of ca- 
theterization is unsatisfactory to 
the surgeon and painful to the pa- 
tient, the length of the angular por- 
tion of the catheter making delicate 
manipulation an impossibility, while 
at the same time it projects so far 
downward that when the instru- 
ment is rotated, considerable irri- 
tation of the pharyngeal mucous 
membrane is produced. Noyes has 
devised a catheter (Fig. 52), the 
pharyngeal extremity of which is 
bent at first downward and then 
upward and outward, which en- 
ables catheterization to be per- 
formed through the opposite nostril 
somewhat more easily than when 
the ordinary Eustachian catheter is 
employed. If the operator uses the 
silver catheters, which, on account 
of their malleability, can be made 
to assume any desired curve, it is 
comparatively simple to convert an 
ordinary Eustachian catheter into 
one possessing a double curve by 
bending it between the fingers. By 
a careful inspection of the nasal passage through which the 
instrument is to be introduced, the operator will be able in 




OBSTACLES TO CATHETERIZATION. 



I2 5 



many instances so to mold the instrument as to render its 
introduction comparatively simple. By giving it the double 
curve already described we overcome the necessity of the 
increased length of the angular portion, which is always a 
source of discomfort to the patient. 

One other method of catheterization remains to be de- 
scribed — viz., the introduction of the instrument through the 
mouth. This was first advised by Kessel * in cases in which 
the nasal passages were occluded. Pomeroy f in this coun- 
try has been an ardent advocate of the procedure, and fre- 
quently employs it in preference to the usual method. He 
has devised a special instrument which is shown in Fig. 53. 




Fig. 53. — Pomeroy's faucial catheter. 



As I have had no personal experience with this method, I can 
give no opinion as to its utility. It is simply mentioned here 
as an available procedure, which may be employed at the dis- 
cretion of the surgeon. 

Deformities of the nasal passages, however, are not the 
only obstacles to catheterization. The exact location, form, 
and prominence of the pharyngeal extremity of the Eustachian 
tube varies not only in different cases, but also in the same 
individual at different times, according to the degree of con- 
gestion of the surrounding parts. The position and shape of 
the pharyngeal orifices may also be asymmetrical in the same 
individual. It frequently happens that the tubal lips are so 
poorly developed that their recognition by the sense of touch 
is almost impossible ; on the other hand, they may be so ab- 
normally developed that difficulty is experienced either in 



* Archiv fur Ohrenheilkunde, vol. xi, p. 21S. 
f Diseases of the Ear. New York, 1SS3, p. 28. 



126 PHYSICAL EXAMINATION. 

drawing- the instrument forward over the posterior lip or, in 
some cases, even in passing it backward sufficiently to permit 
rotation. The pharyngeal vault is occasionally so wide that 
upon rotation the catheter reaches the lateral wall w T ith diffi- 
culty. In such an event the straight portion of the cathe- 
ter must be crowded so far toward the nasal septum as to 
cause considerable discomfort by pressure upon the intra- 
nasal structures, or the angular portion must be so long as 
to render the passage of the instrument through the nasal 
chamber difficult, and to render rotation almost impossible. 

Again, the mouth of the tube may be located high up in 
the vault of the pharynx, and its shape may be such that the 
catheter must be rotated through an angle of at least 135 , 
or even more, before its tip rests in the mouth of the tube so 
as to permit of a fully successful inflation. 

It is only necessary to bear in mind these various obstacles 
in order successfully to overcome them. Delicate manipula- 
tion will enable the operator to recognize the posterior lip of 
the tube after a little practice, even if it projects only slightly 
above the smooth lateral wall of the pharynx. Where the 
pharynx is abnormally wide, the curved portion of the instru- 
ment must be increased in length, and if rotation can not be 
accomplished in the ordinary way, the outer extremity of the 
catheter should be elevated as much as possible to effect a 
corresponding depression of the tip of the instrument, to 
enable it to pass below the tube, after which rotation can be 
performed easily. The timidity of the patient when catheter- 
ization is performed for the first time is another difficulty to 
be mentioned. This is especially the case if the mucous mem- 
brane of the naso- pharynx is irritable, in which event the mus- 
cles frequently contract the moment the instrument enters 
the cavity, and hold it so firmly in their grasp as to prevent 
its rotation into the mouth of the tube. This spasm of the 
palatal muscles causes the instrument to be so firmly grasped 
that its mere presence in the pharyngeal vault is painful. 
The slightest motion augments this pain and increases the 
muscular rigidity, so that it is quite as impossible for the oper- 
ator to withdraw the catheter, as to proceed with the opera- 
tion. Occasionally no inconvenience is experienced until ro- 
tation is attempted, when contact with the lateral wall of the 
pharynx excites the act of deglutition, and the sudden mus- 
cular contraction displaces the catheter and crowds it against 



OBSTACLES TO CATHETERIZATION. 127 

the lateral wall of the pharyngeal space with considerable 
force. If the patient is directed, at the outset, to keep the 
mouth closed and respire regularly and quietly through the 
nostrils, there is much less danger of such reflex muscular 
contraction. If as the instrument enters the pharynx the pa- 
tient shows an inclination to cough or to swallow, it is well to 
divert his attention by requesting him to close the lips and to 
breathe quickly and deeply through the nose. Even an at- 
tempt to do this will cause a momentary relaxation of the 
palatal muscles, and during the interval the introduction of 
the instrument can usually be effected. If reflex contraction 
of the muscles takes place in spite of all precautions, the in- 
strument should be held perfectly still during the period of 
muscular spasm, as any attempt to withdraw or advance it 
adds seriously to the discomfort. Relaxation is sure to take 
place in a few seconds, and then the instrument can be carried 
to the proper position or removed, as seems desirable. Re- 
flex cough occurring during the act of catheterization should 
be managed in the same manner. It is to be remembered that 
when the instrument is once in position, coughing, swallow- 
ing, or any other muscular movement does not interfere with 
it in the slightest, and when correctly placed its presence 
causes no discomfort. 

It occasionally happens that, by mistake, the catheter is 
passed through the middle meatus instead of through the in- 
ferior channel. This need never occur accidentally if the 
head of the patient is maintained in a slightly flexed position. 
The almost irresistible impulse on the part of the patient to ex- 
tend the neck causes the instrument to enter the middle me- 
atus, even when it is passed horizontally inward. With the 
head bent slightly forward this can not occur. It must be 
borne in mind, in conclusion, after discussing the principal 
difficulties met with, and suggesting measures to avoid and 
overcome them, that the utmost gentleness must be exercised 
throughout the entire performance of the operation. The 
catheter should be allowed to find its way into the pharyngeal 
vault, and should be allowed to rotate one way or the other, 
as may seem necessary to avoid obstacles. It is only neces- 
sary for the operator to prevent its passage into the middle 
meatus. When the nasal channel is extremely irregular com- 
plete rotation about the long axis of the catheter frequently 
occurs during its course from the anterior to the posterior 



128 PHYSICAL EXAMINATION. 

nasal opening. The slightest pressure is sufficient to advance 
it when properly directed, and no force should be used. Any 
haemorrhage following catheterization is a reproach to the 
operator in every instance. It is true that an occasional abra- 
sion of the nasal mucous membrane occurs at the hands of the 
most careful manipulator, but one should always feel that 
there is no excuse for the accident. It is a procedure in 
which gentleness and care should be combined with skill, and 
he who can not exercise these is incompetent to carry out the 
operation. 

As to the use of cocaine for the production of local anaes 
thesia, it may be said that since the drug has come into com- 
mon use, it is frequently employed for this purpose in cathe- 
terization. It certainly diminishes the discomfort attending 
the passage of the instrument through the nose, if the channel 
is irregular or narrow, and at the same time by shrinking the 
turbinated bodies increases the width of the nasal passage. 
It may be stated, however, that under normal conditions the 
inferior meatus is not sensitive to the presence of the instru- 
ment, and observations upon quite a large number of cases 
in reference to this point have convinced me that quite as 
much discomfort follows catheterization when local anaes- 
thesia is employed, as when no cocaine is used. In many, the 
disagreeable sensation as of a foreign body in the pharynx, 
due to the drug, constitutes a much greater source of dis- 
comfort than that produced by the introduction of the instru- 
ment without local anaesthesia. No objections can be raised 
to the use of cocaine, however, and it is always wise to em- 
ploy it in cases where the nasal passages are so tortuous as 
to necessitate rather prolonged manipulation. Moreover, the 
knowledge on the part of the patient that the drug has been 
used, certainly produces a profound mental impression, and 
relieves any anxiety as to the discomfort to be endured. The 
drug is best applied in a ten-per-cent solution, a small quan- 
tity being first sprayed into the nostril by means of an ordi- 
nary hand-ball atomizer. A few moments suffice to secure 
contraction of the turbinated tissues, during which time it is 
well to have the head inclined a little forward to prevent the 
passage of the solution into the pharyngeal vault. Next, a 
cotton holder, mounted with a small pledget of cotton mois- 
tened with the same solution, is to be passed through the in- 
ferior meatus, along the course to be traversed by the cathe- 



DANGERS OF CATHETERIZATION. 



129 



ter, the manipulation being conducted under illumination 
from the head mirror. The applicator should not be carried 
beyond the choanae if the unpleasant sensation of fullness in 
the pharynx which the drug" causes is to be avoided. If 
there is reason to suspect that the naso-pharynx will be un- 
usually irritable — a condition with which we frequently meet 
in cases of acute naso-pharyngitis — it is well to anaesthetize 
the mouth of the tube as well as the nasal passages. This is 
done by means of the cotton-tipped probe, the extremity of 
which is bent to correspond to the curve of the catheter. 
Under inspection, this instrument is to be passed through the 
nasal passage exactly as the catheter would be introduced, 
care being taken that the patient's mouth is closed, and quiet 
nasal respiration continued. The same manipulation em- 
ployed in the introduction of the catheter enables the cotton- 
tipped probe to be inserted into the orifice of the Eustachian 
canal, care being taken that the pledget is not saturated with 
the solution, as otherwise a considerable quantity will be 
spread over the pharyngeal mucosa. When the orifice of 
the tube is reached, the applicator is allowed to remain in 
this position for a few seconds to ablate completely the sensi- 
tiveness of the mucous membrane ; catheterization is now 
easily performed. In addition to securing local anaesthesia 
by the introduction of the cotton pledget in the manner al- 
ready described, the operator accomplishes another purpose, 
since he cleanses the orifice of the tube and removes any in- 
spissated secretion which may be present, and which would 
be an obstruction to successful inflation. 

The Dangers of Catheterization. — From the fact that 
three deaths have followed the procedure it is looked upon 
by those unacquainted with the operation with a certain de- 
gree of perturbation. Inflation in these fatal cases was per- 
formed by means of compressed air, the degree of condensa- 
tion being extreme. This method, as already stated, is seldom 
used at present, and it is safe to say that no damage can be 
done with any form of hand apparatus devised for the purpose 
of inflating the middle ear through a catheter. 

Death in these cases was probably caused by suffocation 
from submucous emphysema, due to the air having been 
forced beneath the mucous membrane, the surface of which 
had been abraded by the extremity of the catheter. The oc- 
currence of emphysema need not of necessity be followed by 
10 



^o PHYSICAL EXAMINATION. 

serious results, although the symptoms which supervene are 
always alarming to the patient, and may be disturbing to the 
operator. When this accident occurs, the air may either be 
absorbed spontaneously, or, if the emphysematous area is ex- 
tensive, the condition may demand relief by surgical interfer- 
ence. Puncture of the tissues suffices to evacuate the air and 
to relieve the symptoms at once. It should be stated, how- 
ever, that if even ordinary care is used in catheterization, em- 
physema will never be produced, and one who can not intro- 
duce the Eustachian catheter without abrading the mucous 
membrane of the naso-pharynx had better not introduce it at 
all. The only possible excuse for the accident would be cathe- 
terization immediately after the introduction of the Eustachian 
bougie ; therefore it should be the invariable rule never to in- 
flate the middle ear at once after the passage of such an in- 
strument. 

Occasionally, inflation of the tympanum, either by Polit- 
zer's method or by the introduction of the catheter, is followed 
by immediate dizziness, due to the sudden disturbance of laby- 
rinthine pressure. No judgment can be formed beforehand 
concerning the likelihood of this occurrence. It is always 
well when the procedure is conducted for the first time to 
begin the inflation very gently, allowing but little air to enter 
the tympanum at first, and gradually increasing the strength 
of the current if unpleasant symptoms do not supervene. 
The dizziness, which is sometimes so severe that the patient 
falls from the chair and becomes unconscious for a moment, is 
terrifying, but not dangerous. Where the membrana tym- 
pani is very thin, either as a result of a previous inflammatory 
process with the subsequent formation of cicatricial tissue, or 
from atrophic changes, a forcible inflation may rupture it. It 
follows, therefore, that the use of Politzer's method or cathe- 
terization should be preceded by an inspection of the drum 
membrane. 

The Comparative Value of Politzerization and Catheter- 
ization. — Having now considered these two methods of forc- 
ing a current of air through the Eustachian tubes and into the 
middle ear, a few words as to their relative value may not be 
out of place. As a means of diagnosis, inflation by the catheter 
is always preferable, as it enables the surgeon to estimate the 
force necessary to propel the air through the canal, to observe 
the effect upon the auscultation sounds resulting from varia- 



CATHETERIZATION COxMPARED WITH POLITZERIZATION. 131 

tions in the strength of the air current, and to repeat the ex- 
periment as often as he may desire. Moreover, success or 
failure in accomplishing the end lies entirely in the hands of 
the operator if the catheter is employed, while when the air 
bag is used by Politzer's method, the success or failure lies 
quite as much with the patient as with the surgeon, as it de- 
pends upon his ability completely to close the nasopharyn- 
geal space by elevation of the soft palate. 

In the adult the auscultatory sounds are so weak when Po- 
litzer's method is used that very little information is gained 
by using the diagnosis tube. In children under twelve years 
of age, however, the Eustachian canal is quite short, and its 
calibre comparatively large in proportion to its length. At 
this age catheterization is somewhat difficult, while the air bag 
fitted with a proper nose piece usually opens the tube per- 
fectly, and the sounds produced within the tympanum are suf- 
ficiently strong to be perceived through the diagnosis tube. 

As a diagnostic measure, then, Politzer's method should 
be used in young children and in those cases where the nasal 
passages are obstructed to such an extent that the introduc- 
tion of the catheter is well-nigh impossible. 

As a therapeutic measure the catheter is decidedly supe- 
rior to Politzer's method, allowing as it does the inflation of 
either ear without disturbing the organ of the opposite side 
and permitting the application of various medicated vapors 
directly to the membrane of the tube and tympanum, without 
bringing them in contact with the mucous membrane of the 
nasal cavity. 

When Politzeration must be employed from necessity, the 
action of the air may be confined to one ear by the insertion 
of the finger into the opposite meatus, thus compressing the 
air in the canal and rendering any appreciable outward dis- 
placement of the membrana tympani impossible. The ad- 
vantage of catheterization, mentioned in comparing the two 
methods for diagnostic purposes, holds good in this connec- 
tion as well — that catheter inflation allows an exact srradua- 
tion of the force employed, the bulb being pressed more or 
less strongly as indicated by the freedom with which the 
air passes into the middle ear. The objection so frequently 
raised against catheterization — that the instrument inflicts a 
certain amount of traumatism on the structures against which 
it impinges — need scarcely be mentioned. It is quite true 



132 



PHYSICAL EXAMINATION. 



that harsh catheterization always does more damage than 
good, but harsh catheterization is never to be employed, for, 
as before stated, the exercise of care will enable even the be- 
ginner to introduce the instrument without inflicting any in- 
jury, even if he is not successful in directing the instrument 
into the pharyngeal orifice of the tube. 

The Examination of the Nose, Naso-pharynx, and Phar- 
ynx. — Under no circumstances should the surgeon consider 
his physical examination complete until he has inspected the 
regions above mentioned which, by their anatomical position, 
exert a powerful influence upon the ear both in health and in 
disease. 

As the mucous membrane lining the nasal cavities and the 
naso-pharyngeal space is continuous with that lining the mid- 
dle ear, an intimate relation exists between the nerve and 
blood supply of the two regions, rendering the ear particu- 
larly susceptible to reflex disturbances depending upon some 
intranasal exciting cause, as well as to circulatory changes 
from alterations in the blood and lymph current within either 
the nasal chambers or the pharyngeal vault. After a satis- 
factory otoscopic examination has been made, the next step 
should be to inspect the oral cavity by means of reflected 
light, observing the condition of the mucous membrane in 
the mouth ; the presence of carious teeth ; the appearance of 
the posterior pharyngeal wall, whether it is dry or moist ; 
whether it presents the smooth, velvety appearance of a nor- 
mal mucous membrane, or is studded here and there with 
irregular elevations, indicative of the presence of small lymph 
nodules just beneath its superficial epithelial layer In this 
connection attention need scarcely be called to the importance 
of observing those two large masses of lymphoid tissue situ- 
ated between the pillars of the fauces — that is, the faucial ton- 
sils. Under normal conditions the tonsils do not project be- 
yond the faucial pillars, and special effort must be made to see 
them in a condition of perfect health, by crowding the ante- 
rior faucial pillar against the lateral wall of the pharynx, or 
turning the head of the patient first to one side and then to 
the other, to permit the observer to look obliquely across the 
cavity of the mouth, in order that they may be brought into 
view. Any projection of these bodies beyond the pillars of 
the fauces constitutes an abnormity. 

The vault of the pharynx next demands investigation. In 



EXAMINATION OF THE UPPER AIR PASSAGES. 133 

very young children posterior rhinoscopy is impossible, and 
here resort may be had to digital examination. In this pro- 
cedure the mouth of the patient should be held open by a cork 
inserted far back between the jaws, or better by the use of a 
mouth gag. The index finger, with the palmar surface down- 
ward, should then be introduced into the opposite angle of the 
mouth. It should then be passed rapidly along the dorsum 
of the tongue until it meets the posterior pharyngeal wall, 
when, by quickly turning the palmar surface upward, it is 
passed behind the soft palate into the naso-pharyngeal space, 
the palate yielding readily to gentle but firm traction. By 
drawing the finger forward the nasal septum should now be 
recognized and followed upward until the roof of the cavity 
is felt. The sensation imparted to the examining digit should 
be observed : whether the membrane is soft and spongy, in- 
dicative of the presence of an abnormal amount of lymphatic 
tissue, or whether it differs but little from the sensation im- 
parted by the mucous membrane covering the posterior wall 
of the oro-pharynx. These facts having been determined, the 
tip of the finger is turned first to one side and then to the 
other, and easily appreciates the Eustachian prominences, 
after which it is withdrawn ; by sweeping along the posterior 
wall of the naso-pharynx in making its exit, the presence of 
any abnormal amount of lymphoid tissue in this location is 
determined. 

The presence of adenoid tissue in the vault of the pharynx 
affects the ear in two ways. If the mass is large, by direct 
pressure upon the Eustachian orifice the supply of air in 
the tympanic cavity may be disturbed. This fact will be ap- 
preciated by reference to Fig. 50. It is evident that the en- 
larged pharyngeal tonsil, seen in this drawing, lies so closely 
to the posterior lip of the tube that any increase in volume 
would interfere with the patency of the canal. Any slight in- 
crease in volume of the mass will close the lumen of the tube, 
after which the intratympanic air is gradually absorbed by 
the blood which circulates through vessels in the walls of 
the cavity. With each act of swallowing, at which time the 
tube opens momentarily, the air is aspirated into the naso- 
pharynx, the tube closing so quickly that the passage of air 
into the tympanum does not take place. In this manner a 
passive congestion of the mucous membrane of the middle 
ear is produced, a condition which constitutes practically the 



134 PHYSICAL EXAMINATION. 

first stage of an inflammation, and, if long continued, results 
in permanent tissue changes. 

I am inclined to think the more important manner in 
which adenoid growths, especially those of moderate size, 
affect the organ of hearing is by the obstruction to the ve- 
nous return current from the tympanum and labyrinth. It 
must not be forgotten that the pharyngeal tonsil constitutes 
nothing more than a lymphatic gland, and, in virtue of its 
presence, may exert sufficient pressure to partially obstruct 
the venous flow from the tympanic cavity. Any condition 
which affects, for a considerable period, the circulation within 
the middle ear, will also cause a disturbance of the labyrin- 
thine circulation from an alteration in the tension of the fluid 
contained. Such changes in the labyrinth, however slight, 
render this portion of the economy particularly susceptible to 
inflammation, either as the result of infection or of mechan- 
ical irritation, the most fruitful source of the latter being the 
crowding inward of the ossicular chain by atmospheric pres- 
sure, when the tension of the air within the tympanum is re- 
duced. Evidence is not wanting, from a clinical point of 
view, that even in very early life the labyrinth may be af- 
fected by the presence of growths of this kind. We not un- 
commonly find instances of tubal catarrh in children in whom 
these growths are present ; instead of presenting, upon func- 
tional examination, the reactions characteristic of the affec- 
tion, these cases show a diminution of bone conduction, and 
sometimes a hyperassthetic condition of the auditory nerve, 
both of which phenomena indicate an irritative lesion of the 
labyrinth. In very young children it is of the utmost impor- 
tance to determine the presence or absence of a growth of 
this kind, even where the history seems to show that the child 
is entirely deaf, for, as articulate speech is acquired simply 
by imitation, an impairment of audition which in an adult or 
in a child of a few years of age would be practically insig- 
nificant, in a child so young that the function of audition has 
never been exercised, may give rise to all the symptoms usu- 
ally found in a deaf-mute. 

The oro-pharynx and the pharyngeal vault having been 
examined in the manner stated, attention should next be di- 
rected to the anterior nares. The nasal cavity should be 
inspected by anterior rhinoscopy, the tip of the nose being 
tilted up by means of the thumb of the left hand, the fingers 



EXAMINATION OF THE UPPER AIR PASSAGES. 



135 




of the hand resting upon the forehead for support, while the 
nasal orifice is dilated gently with a self-retaining speculum 
(Fig. 54). The patient's head should be flexed slightly for- 
ward, in such a position that the floor of the nasal cavity will 
be nearly horizontal. When the light from the head mirror 
is directed into the cavity 
the observer inspects first 
the inferior meatus, and 
remarks if any deformity 

of the septum is present, 

1 , • • Fig. 54. — Bosworth's nasal 

determining its extent, na- 10 speculum 

ture, and location, as well 
as the size, shape, and color, of the inferior turbinated body; 
whether it is turgescent and occludes the inferior meatus to a 
considerable extent, or whether its mucous membrane is of 
the normal light rosy tint, and its rich venous plexuses are 
not abnormally engorged. Under normal conditions, where 
no deformity of the septum exists and the turbinated tissue is 
not swollen, the observer can readily see the posterior wall of 
the naso-pharynx by anterior rhinoscopy, and, in fact, the au- 
thor has found this one of the most simple methods of deter- 
mining the presence of hypertrophied lymphatic tissue in this 
region. This portion of the examination is rendered more 
complete if a weak solution of cocaine is sprayed into the an- 
terior nares, before an attempt is made to inspect the naso- 
pharynx in this manner. The anaethesia this produces renders 
it the simplest possible procedure to add to our information 
by touching the various parts under inspection with a cotton- 
tipped probe passed through the anterior nares. The inspec- 
tion of the lower meatus and naso-pharynx having been com- 
pleted, the head is now tilted backward, and the observer di- 
rects his attention to the upper part of the nasal chamber. In 
the anterior portion the eye recognizes readily the tip of the 
middle turbinated body, which, normally, is of a somewhat 
lighter color than the lower turbinate and less freely supplied 
with venous channels, for which reason its mucous membrane 
seems to be more closely applied to the bony framework, the 
entire structure projecting less into the lumen of the passage 
than does the inferior turbinate. Any deviation from this 
normal appearance should be carefully noted as constituting 
a source of obstruction to nasal respiration. It should be re- 
membered that the furrow or hiatus beneath the middle tur- 



I3 6 PHYSICAL EXAMINATION. 

binated body contains the opening of the frontal, anterior, 
ethmoidal, and maxillary sinuses ; consequently it should be 
inspected with special care for the presence of a purulent dis- 
charge which, when lying here, is almost pathognomonic of 
an inflammation of one of these accessory cavities. This also 
is the region from which nasal polypi most frequently take 
their origin, and the possible presence of these growths must 
always be borne in mind during this stage of the examination. 

We have spoken only of the hypertrophic condition, since 
this is the lesion usually presented in cases which come under 
the observation of the otologist. It must be remembered, how- 
ever, that precisely the opposite state of affairs may constitute 
a morbid condition — that is, instead of an hypertrophy of the 
lining membrane, this may be abnormally thin, the turbinated 
bodies lying close to the outer wall of the passage and project- 
ing but little into the lumen. When the condition is extremely 
well marked, they are discernible with some difficulty. Under 
these circumstances the mucous membrane, instead of being 
moist, has a dry, glazed appearance, while in the sulci be- 
tween or beneath the turbinated bodies, large greenish-yellow 
crusts are seen. These result from the inspissation of the nasal 
secretion, which, owing to the atrophy of the lining mem- 
brane, is wanting in fluidity. The naso-pharynx also, instead 
of showing the presence of lymphatic tissue, may appear 
glazed, and may be covered, to a greater or less extent, with 
a thick, tough mucus, usually in the form of a scale or shell, 
which spreads irregularly in all directions from the median 
line. This naso-pharyngeal condition is seldom found before 
the age of twenty, and is usually due to retrograde changes in 
the lymphoid tissue of the region, which in early life had un- 
doubtedly been moderately but not excessively hypertrophied. 
Instead of disappearing completely after the age of puberty, 
as is often the case, interference with this retrograde process 
occurred for some reason, with the result that the fibrous 
elements of the pharyngeal tonsil persisted and increased in 
density, while the cellular elements disappeared. This local 
condition constitutes the lesion in the cases of so-called naso- 
pharyngeal catarrh, or chronic naso-pharyngitis. The ap- 
pearance described can be recognized both by the anterior 
rhinoscopic examination, and by posterior rhinoscopy as well. 

By posterior rhinoscopy we are enabled to obtain a view 
of those structures which are hidden from direct inspection 



EXAMINATION OF THE UPPER AIR PASSAGES. 137 

by the curtain of the soft palate. This is accomplished by 
means of a mirror introduced into the mouth, with the reflect- 
ing- surface directed upward, so that the image of the region 
in question is reflected in the mirror. In order to conduct 
this examination the patient is seated facing the surgeon, the 
arrangement of the light and the relative positions of the pa- 
tient and operator being the same as those already given un- 
der the description of otoscopy. The head of the patient is 
inclined very slightly forward so that the hard palate lies in 
the horizontal plane. The surgeon now depresses the tongue 
with the tongue depressor held in the left hand, crowding the 
organ downward while, at the same time the instrument is 




Fig. 55. — Bosworth's tongue 
depressor. 





Fig. 56. — Folding tongue depressor. Fig. 57. — Turck's tongue depressor. 

rotated slightly by elevating the handle, the blade resting 
upon the incisor teeth, thus exerting slight forward traction. 
In this way efforts at retching on the part of the patient are 
avoided, as the base of the tongue, instead of being crowded 
into the throat, a circumstance which always results in ex- 
citing an effort of deglutition, is drawn forward out of the 
pharynx. The patient is directed to breathe quietly, and 
at an opportune moment, when the palatal muscles are re- 
laxed and the velum hano-s vertically downward, the rhino- 



138 



PHYSICAL EXAMINATION. 



scopic mirror, previously slightly warmed over the lamp, is 
carried rapidly into the mouth and made to assume a position 
to the one side or the other of the uvula. The rays of light 
from the head mirror are directed upon the surface of the 
rhinoscopic mirror, which, as the inclination of its polished 
surface is about one hundred and thirty-five degrees, directs 
the rays impinging upon it into the retronasal space. At first 




FlG. 58. — Rhinoscopic mirror. 



the handle of the mirror should be carried slightly downward, 
which brings into view the posterior margin of the nasal sep- 
tum ; this should be followed upward until its narrow edge is 
seen gradually to broaden and finally to disappear in the upper 
wall of the naso-pharynx. In bringing the septum into view 
the presence of an hypertrophied posterior extremity of either 
lower turbinated body will easily be recognized by its marked 
encroachment upon the lumen of the corresponding posterior 
nasal orifice. In the same manner myxomatous growths, 
springing from the nasal cavities and extending into the naso- 
pharyngeal space, will also be easily discovered. Any in- 
crease in the lymphatic tissue near the pharyngeal roof will 
be at once evident, as its presence renders it impossible for 
the observer to follow the outline of the septum upward to 
where the divergent edges are lost in the pharyngeal roof 
the expanded portion of the septum being concealed by the 
hypertrophied lymphatic tissue. By gradually elevating the 
handle of the mirror the entire roof and a portion of the 
posterior wall of the naso-pharynx are brought into view, 
and by rotation of the mirror upon the long axis of the shank 
each lateral wall of the cavity is inspected and the prominent 
posterior lip of the Eustachian tube upon either side easily 
recognized. Behind this we observe the fossa of Rosenmul- 
ler, while in front is the orifice of the Eustachian tube, which 
varies in shape from a slitlike depression, to an opening with 
distinctly circular borders. (Figs. 49-51.) 

Preparation of Instruments. 

Before concluding the subject of the physical examination, 
a few words will not be out of place concerning the care of 
instruments used in conducting the examination. Too much 



PREPARATION OF INSTRUMENTS. 



139 



stress can not be laid upon the necessity of absolute asepsis. 
All metal instruments should be sterilized by boiling in a two- 
per-cent sodium-bicarbonate solution before each examina- 
tion. If rubber catheters are to be used, each patient should 
possess his own instrument, while if silver catheters are used 
they should be sterilized in the manner above described. 

In cleansing the ear with a syringe, an aseptic solution or, 
better still, an antiseptic solution should always be employed. 
A solution of bichloride of mercury in the proportion of 1 to 
5,000 is sufficiently antiseptic to prevent infection of the tym- 
panic cavity if the drum membrane is accidentally perforated 
during the process of cleansing the canal. The tip of the ear 
syringe should be boiled immediately before use, or, if this is 
not convenient, the extremity should be covered by a small 
piece of soft-rubber tubing, which is renewed each time the 
syringe is used. 

As the prolonged boiling of tempered instruments is inju- 
rious, these may be thoroughly cleansed with cotton and then 
dipped for a moment in the boiling soda solution, after which 
they are immersed in a five-per-cent solution of carbolic acid 
for several minutes. 

It is scarcely necessary to call attention to the necessity 
of personal cleanliness on the part of the operator, and yet 
perhaps this is occasionally forgotten. 

These measures have been recommended by many writers 
to avoid specific infection chiefly. In this country, where 
specific disease is not as common as upon the Continent, the 
above precautions are scarcely necessary for this purpose, 
but they are necessary to prevent purulent infection of the 
middle ear. 

If the above precautions are adopted in every case, the 
extent to which operative procedures within the middle ear 
can be carried is surprising. In no region of the body, per- 
haps, is asepsis more important, and nowhere certainly has 
it been so utterly disregarded. 

The History. 

A very important part in the intelligent investigation 
of any affection of the ear, involving a partial loss or per- 
version of its function is the general history of the patient., 
together with an exact account of the aural affection. It 
is scarcely necessary to give more than briefly the various 



I 4 PHYSICAL EXAMINATION. 

subjects which should be investigated, before any decided 
opinion is given as to the nature of the affection or the prob- 
able course which it will pursue. These facts influence our 
opinion not only as to the favorable or unfavorable progress 
of the disease, but in no small degree enable us to determine 
the relative value of the various data with which our physical 
and functional examinations furnish us. The age of the pa- 
tient, the occupation, and the habits of life should be first con- 
sidered. The history of any previous illness must be investi- 
gated with great care, particularly concerning the occurrence 
in childhood of any of the exanthemata and other kindred 
diseases, and later in life of any of the continued fevers. A 
not unimportant factor is the presence of an hereditary taint 
— tuberculous, specific, gouty, or rheumatic — as well as the 
existence of chronic aural disease in any other members of the 
family. The habits of the patient regarding the use of opiates, 
stimulants, tobacco, indulgence in the luxuries of the table, 
or the fact of his having been called upon at any time to 
undergo severe mental strain or physical exertion, must also 
receive consideration. Special attention should also be paid 
as to whether, at any period of life, it has been necessary for 
him to take continuously large doses of the various drugs which 
are known to have a specific action on the auditory organs. 

Next the status prcesens should receive attention, particu- 
larly with reference to the digestive system, and here it must 
not be forgotten that the mouth is responsible for quite as 
much aural disturbance as the stomach, and inquiry should 
be made into the condition of the teeth. Any previous or 
present condition referable to the pelvic organs must also be 
inquired into. Much information may frequently be obtained 
by observing the general behavior of the subject in respond- 
ing to the various questions, it being remembered that, in 
patients of a decidedly neurotic tendency, care must be ob- 
served in the interpretation of the apparent results obtained 
by a functional examination, the mere fact that they are under 
examination often disturbing them to such a degree that their 
answers are entirely untrustworthy. 

When we come to the special history — that is, that part 
which bears directly upon the aural affection for which they 
seek advice — the length of time which this has existed must, if 
possible, be determined. It is of special importance to inquire 
into the condition of the ears in childhood, as not infrequently 



THE HISTORY. I 4 I 

the patient may neglect to state the presence of aural symp- 
toms in early life, conceiving that as these have apparently 
disappeared, they can have no bearing upon the present 
affection. The symptoms upon which the patient lays most 
stress generally, are impairment of hearing, tinnitus, discharge 
from the ear or pain in this location. Nausea, vertigo, general 
headache, etc., may have a very important bearing upon the 
malady, yet may be referred by the patient to entirely differ- 
ent causes and hence remain unmentioned unless he is ques- 
tioned especially with reference to their previous existence. 
If the affection has been of long duration it is of the greatest 
importance to discover whether the progress has been unin- 
terrupted, or whether under certain conditions it has been 
aggravated. In this connection the effect upon the ear of an 
acute inflammatory condition of the mucous membrane lining 
the nose or naso-pharynx, or of an aggravation of already ex- 
isting catarrhal disturbances, is to be discovered, the intimate 
relation between the upper air tract and the organ of hearing 
rendering this of great moment. It may be taken as an almost 
invariable rule where the aural symptoms are intermittent 
in character, becoming more severe when the patient suffers 
from a cold in the head, that even if the pathological process 
is located in the middle ear, our treatment must be directed 
quite as much to the upper air passages as to the tympanum 
itself in order to obtain permanent benefit. 

If the prominent symptom is an impairment of hearing or 
the presence of tinnitus we should discover under what con- 
ditions these are most troublesome — whether the patient hears 
better in a noisy or in a quiet place ; whether the chief diffi- 
culty is that it is impossible to understand general conversa- 
tion, or whether the impairment is so marked that even dia- 
logue is impossible. Ascertaining the particular time during 
the day when the disturbance is most severe — whether in the 
morning, after a refreshing night's sleep, or at the end of the 
day, when tired both physically and mentally — may often aid 
us in forming our opinion. A word of caution should be 
added lest the physician may, by attaching too much impor- 
tance to any one symptom, cause the patient to exaggerate it 
unduly. This is especially true in questioning him concern- 
ing his tinnitus. If distressing, he will complain of it without 
interrogation, but if this is not the case, only the most casual 
mention should be made regarding its presence. 



CHAPTER IV. 

FUNCTIONAL EXAMINATION. 

As the aural surgeon is consulted most frequently on ac- 
count of either impairment or perversion of function in the 
auditory apparatus, it would seem natural that he could arrive 
at the most perfect conception of the condition of this appa- 
ratus by testing the functional condition of the organ of hear- 
ing. It is strange, however, that while much attention has 
been paid to the observation of physical changes in the ex- 
ternal and middle ear, which may be noted by ocular inspec- 
tion, the functional examination has ordinarily been conducted 
in the most superficial manner. 

By recalling the remarks made under Physiology, it will 
be remembered that the ear perceives not only the intensity 
of a sound, but also its pitch or quality ; consequently a 
functional examination is complete only when it estimates 
both the qualitative and quantitative condition of audition. 

I. Quantitative Tests. — In order to determine how much 
the quantitative function of the ear is impaired, it is only 
necessary to compare the distance at which any given sound 
is heard by the ear under examination, with the distance at 
which it is perceived by the normal ear. 

For convenience, the hearing power is ordinarily ex- 
pressed as a fraction, the denominator of which represents 
the distance in feet or inches at which the sound is normally 
heard, while the numerator designates the distance at which 
the sound is perceived in the affected ear under examination. 

It should be borne in mind that as a single sound excites 
only one part of the perceptive apparatus, an ear which may 
be perfectly healthy otherwise may fail to perceive one sound 
on account of the destruction of this particular area in the 
cochlea, and in order to apply this test we must be certain 
that the perceptive mechanism w T ill respond to the particular 
standard sound to be employed as a unit. In order that the 

(142) 




QUANTITATIVE TESTS. 143 

results of various observers may be compared, use must also 
be made of a sound of a given quality and intensity ; and 
herein lies one of the chief difficulties of comparing the re- 
sults of tests made by different observers. 

The sound most commonly employed in making a quanti- 
tative test, where the hearing is but moderately impaired, is 
the tick of the watch. While this may be fairly accurate in 
observations made by the same individual, it is manifestly 
impossible that any comparison of results reached by several 
examiners can be made. To obviate this difficulty, Politzer* 
devised the instrument shown in Fig. 59, which is supposed 
to produce a sound whose intensity and quality are always 
the same. This, perhaps, is the most uni- 
versally used apparatus for conducting 
experiments of this kind. The chief ob- 
jection is that as the sound produced by 
the instrument is heard by the normal 
ear at a distance of forty-five feet, its 
use is restricted to those cases in which 

. . f . . . Fig. 59. — Pohtzer s acou- 

the impairment of hearing is considera- meter. 

bie. Moreover, it is not impossible that 

the particular portion of the perceptive apparatus which is 
responsive to this sound may be so affected that, while the 
function of the organ as a whole may improve, the distance 
at which this sound is perceived may remain unchanged. 

The ideal test in estimating impairments of audition is 
the human voice, since the patient desires especially that 
the power of audition for sounds thus produced shall be im- 
proved, and, moreover, because his own estimate of the prog- 
ress of his disease is very largely based upon the ease or diffi- 
culty with which he is able to understand the human voice 
in ordinary conversation. Therefore, no matter what me- 
chanical appliance may be used in estimating the power of 
audition, no system of examination is complete which fails to 
record the facility with which various vocal sounds are per- 
ceived. Since the conversational voice varies greatly both 
in pitch and intensity in different individuals, an exact com- 
parison of the results obtained by using the conversational 
voice as a standard would be difficult. The whisper, how- 
ever, is fairly constant in pitch and intensity, if care be taken 



* Archiv fur Ohrenheilkunde, vol. xii, p. 104. 



144 FUNCTIONAL EXAMINATION. 

that in every examination the whisper shall be as loud as 
possible, or what may be termed " a forced whisper." The 
examiner in carrying out this test should first fill the lungs by 
a forced inspiration, and then allow them to empty them- 
selves by a normal expiratory effort, after which he should 
repeat in a whispering voice the particular word or words to 
be used as the test. I have taken pains to compare the data 
obtained by various observers by tests conducted in this 
manner, and find that the error of experiment is very small 
when the test is conducted carefully. It should be remem- 
bered that the patient soon becomes familiar with sentences 
used in these experiments, and when the same phrases are 
repeated frequently the results obtained are worthless. To 
avoid this result, Siebenmann * advises the use of numbers of 
two figures. In this way the patient can not become familiar 
with any given test sentence, as the same numbers are not 
repeated on successive examinations, or if repeated, their se- 
quence is changed. We meet, however, with the difficulty 
that certain combinations of letters are more easily perceived 
than others, even when whispered with the same intensity — 
in other words, each vowel and consonant sound possesses an 
intensity peculiar to itself, the vowel sounds being more eas- 
ily heard than consonant sounds. This characteristic of indi- 
vidual letters is denominated their logographic value, and the 
appended table, prepared by Blake, exhibits the relative in- 
tensity of the consonant sounds ; the T sound being that of 
the greatest intensity, its value for purposes of comparison is 
denominated in the table as ioo: 



T = ioo 


B = 53 


K = 3 i 


Z= 63 


D-45 


L = 21 


C= 62 


S = 40 


N=n 


p= 58 


F = 35 


M= 9 


G= 56 







If proper care is exercised in the selection of numbers of 
two figures, or if the numbers are selected at random, and 
the average results of ten experiments be taken as represent- 
ing the quantitative value of the hearing in any particular case, 
a fairly accurate estimate of the condition may be obtained. 

Instead of estimating the distance at which a sound of 

* Archives of Otology, vol. xxii, p. 1. 



QUANTITATIVE TESTS, 145 

known intensity is heard, another fairly accurate method 
consists in comparing- the time during which a given musical 
note is perceived by the defective organ, with the perception 
time of the normal ear. The sounding body is set in vibration 
by a constant force, and the relation is expressed in the form 
of a fraction of which the normal perception time is the de- 
nominator and the perception time of the defective ear ex- 
amined is the numerator. While not absolutely accurate from 
a mathematical point of view, the error is so slight that it 
may be practically disregarded, as proved by the experiments 
of Barth.* The only difficulty in testing in this manner is in 
obtaining a constant force for setting the tuning fork or any 
other convenient instrument in vibration. If each examiner 
determines his own standard experimentally, by estimating 
the time during which the fork is heard by the normal ear, it 
being set in vibration by a blow which habit has enabled him 
to make fairly constant, a comparison of such results will be 
perfectly possible and fairly accurate, it being only necessary 
that the rate of vibration, or the pitch, of the instrument be 
known, and that its note be pure — that is, free from over- 
tones. The note usually employed is that of a tuning fork 
making five hundred and twelve V. D., which corresponds to 
the treble C of the musical scale, as it is more easy to con- 
struct an instrument of this pitch, free from overtones, than 
one of lower pitch. 

It is scarcely necessary to mention the more complicated 
instruments which from time to time have been devised for 
determining quantitative audition. Their use has never be- 
come universal on account of their complex construction. 
The phonograph, supplied with a series of standard cylin- 
ders and capable of reproducing sounds which shall always 
be uniform both in pitch and intensity, is probably the most 
simple of these devices. The principle of the telephone has 
been used in constructing instruments for this purpose. Of 
these, probably that recommended by Urbantschitsch f is the 
best. The operation of this instrument and of other kindred 
devices depends upon gradually diminishing the intensity of 
a given sound by sliding the secondary coil of an induction 
apparatus, introduced into the circuit, over the primary coil. 



* Archives of Otology, vol. xvii, p. 153. 

f Lehrbuch der Ohrenheilkunde, Vienna, 1S90, p. 39. 



146 



FUNCTIONAL EXAMINATION. 



The sound is conveyed to the ear of the patient by means of 
an ordinary telephone. 

In the instrument shown in Fig. 60 the sound employed is 
produced by the rapid interruption of the electric current by 
Neef's hammer. It is necessary that the vibrating- hammer 
be completely inclosed, in order that its repeated blows may 
not be heard through the air in cases where the hearing is 




Fig. 60. — Urbantschitsch's electric acoumeter. £, Primary battery ; N, Neef's ham- 
mer for interrupting the current automatically, and thus producing the sound to 
be employed in conducting the test ; 2, 2', Induction coils of equal size, but 
wound in opposite directions ; 1, Movable helix ; T, Telephone ; S, Screw for 
moving the helix. As the helix is withdrawn from one secondary coil, it enters 
the other, which is wound in the opposite direction, and the intensity of the 
sound heard through the receiver is thus increased or diminished at will. (Ur- 
bantschitsch.) 

but slightly impaired, or by the opposite ear, where there is 
great impairment upon one side, the opposite organ being 
normal or nearly so. 

A somewhat similar instrument has been devised by Gra- 
denigo,* in which the source of sound is a metal rod producing 
a pure musical note corresponding to C in the musical scale* 



* Handbuch der Ohrenheilkunde von 
P. 383. 



Schwartze, Leipzig, 1893, vol. 



QUANTITATIVE TESTS. 147 

This certainly possesses advantages over the instrument just 
described, in which the quality of the sound must vary con- 
siderably. 

The maximal phonometer was devised by Lucae * to meas- 
ure the intensity of a vocal sound by observing to what extent 
the vibrating column of air displaced a diaphragm upon which 
it was made to impinge. The instrument is too complicated 
to be used universally. 

Whatever method is adopted in making a quantitative test, 
certain precautions must be taken to avoid error in cases 
where a marked impairment of hearing exists in one ear, with 
only a very slight impairment in the function of the other. 
It is impossible to prevent the normal ear from perceiving 
sounds of great intensity, no matter how tightly the external 
auditory canal is closed, and as a preliminary step to the ex- 
amination it is essential that the test sound employed shall 
act upon the organ under examination alone. 

We begin, then, by placing the patient in such a position 
that the ear to be examined is turned toward the source of 
sound ; the opposite meatus is tightly closed by the finger 
of the patient or, better still, by that of an assistant. To se- 
cure perfect occlusion the digit should be previously mois- 
tened with water. When the hearing is impaired to a great 
degree and we have reason to doubt the efficiency of this 
method of excluding sound from the opposite ear, at the con- 
clusion of the examination of the affected ear, both external 
auditory canals should be closed and the examination re- 
peated. If now the patient hears equally well with both 
canals closed, it is evident that the affected ear exerted no in- 
fluence upon the results obtained by the first tests — in other 
words, that the ear upon this side is totally deaf. If, how- 
ever, the results are not the same, the hearing power upon 
the affected side is obtained by subtracting the perception 
distance obtained by the last experiment from that elicited by 
the first. 

It is possible, under certain conditions, to convey the sono- 
rous vibrations to the affected ear through a tube, the sound- 
ing body being removed to a distance sufficient to prevent 
perception by the organ of the opposite side. This is par- 
ticularly valuable if the method is adopted of estimating the 

* Archiv fur Ohrenheilkunde, vol. xii, p. 2S2. 



148 



FUNCTIONAL EXAMINATION. 






hearing power by comparing interval during which the sound 
is perceived, with that of the normal ear. 

II. Qualitative Tests. — We recall that the normal ear per- 
ceives vibrations as musical notes repeated at regular intervals 
from 16 V. D. to about 32,500 V. D. These, 
then, may be called the lower and upper 
limits of audition, respectively. When the 
organ is functionally perfect these limits 
vary but slightly. When, however, either 
the perceptive or transmitting mechanism is 
the seat of a pathological process, these lim- 
its are changed in a characteristic manner. 

To complete our functional examination, 
then, it is essential to be provided with some 
convenient device for producing the lower 
notes of the musical register — that is, from 
16 to 20 V. D. to 64 V.D. per second — and 
also some instrument which will emit the 
shrill, high-pitched sound, caused by im- 
pulses following each other with extreme 
rapidity. The first requisite is easily ob- 
tained through the medium of a tuning fork 
of large size. If provided with clamps, a 
single instrument may, by altering the posi- 
tion of these, be made to vibrate at varying 
rates. The fork shown in Fig. 61 answers 
this purpose fairly well. When the clamps 
are fastened at the extremity of the branches 
of the fork the instrument makes about 26 
V. D. When a little care is exercised in set- 
ting the fork in vibration, this note is prac- 
tically pure and is easily perceived as a mu- 
sical sound. When the clamps are moved 
down, so that about half the length of each 
clamp extends beyond the free extremity of 
the arm of the fork, as shown by the dotted 
lines in Fig. 61, the rate of vibration increases 
to about thirty per second. When carried 
still lower, the note corresponds very nearly to the contra C 
of the musical scale. If the clamp is entirely removed the fork 
emits a pure note corresponding to the next octave higher; 




Fig. 61. — The au- 
thor's tuning fork 
for determining the 
lower tone limit. 
The instrument is 
provided with ad- 
justable clamps. 



Ill 



other words, it makes sixty-four vibrations per second. 



QUALITATIVE TESTS. 



149 



While this device does not by any means allow us to ex- 
amine the lower portion of the scale as thoroughly as we may 
desire, it reveals very quickly any deficiency in audition for 
the lower notes of the scale. 

The Galton whistle affords a simple means of producing 
the higher notes of the musical scale, for determining the up^ 
per tone limit. This apparatus is essentially a closed organ 
pipe in which the column of air is set in vibration, either 
through the medium of the expired air, by holding it between 
the lips, or, better still, by means of a rubber ball fitted to 
its open extremity. By a well-known law of physics, if the 
diameter of a tube is uniform, the note produced by forcing 
air through it will become higher and higher as the length of 
the tube diminishes. Thus, if the length is diminished one 
half, the resulting note will be an octave higher than the funda- 
mental tone of the original tube, and by decreasing the length 
of the tube gradually, all of the various musical notes may 
be obtained between the fundamental tone of the tube and 
that emitted by a pipe of infinitesimal length. 

The length of the tube is reduced by a metal obturator, 
which is slowly advanced along its lumen through the agency 
of a screw ; the outer surface of the tube is graduated, each 
division of the vertical scale representing the space traversed 
by the obturator during a single complete rotation of the 
screw. 

Owing to the fact that so many of the instruments sold 
are not made according to a fixed rule, the graduations of the 
scale can not be employed in comparing the results obtained 
by examination with different instruments. It has seemed 
wise, therefore, to state here briefly the means by which the 
number of vibrations per second which any instrument of this 
kind produces may be determined. 

The Galton whistle acts as a closed organ pipe, and the 
variation in pitch of the notes produced depend upon the phys- 
ical rules which govern the construction of wind instruments 
of this class. By the law of closed tubes the length of the 
tube producing a given note is one quarter the wave length. 
Without going into detail, it will be sufficient to state that in 
any instrument of this character the number of vibrations per 
second may be calculated by dividing the velocity with which 
sound travels by four times the length of the closed tube. 
Sound travels through the air, at the average temperature, at 



150 FUNCTIONAL EXAMINATION. 

the rate of eleven hundred and eighteen feet per second ; this 
number, divided by four times the length of the tube which 
produces the note in question, will give the rate of vibration. 
In other words, the result obtained by dividing eleven hun- 
dred and eighteen feet by the length of the tube, is equal to 
four times the number of vibrations producing the funda- 
mental note of the tube. 

A more exact method of determining the upper tone limit 
is by means of a series of rods, known as Koenig's rods. 
These small steel cylinders are of various lengths, the diam- 
eter of each being the same. To elicit the primary note of 
one of these rods it is suspended by means of loops of very 
light wire or of silk thread, from points equidistant from the 
two extremities of the cylinder, the location of the points 
of support being determined by certain mathematical laws. 
These cylinders are set in vibration by a small metallic ham- 
mer and emit a pure tone, the pitch of which varies with the 
length of the cylinder. This method of determining the 
upper tone limit is probably more exact than that in which 
the Galton whistle is used, but it is much more tedious, and 
for clinical purposes yields scarcely better results. 

By the low-pitch tuning fork and the Galton whistle we 
may determine the limits between which musical notes are 
perceived. Bezold * advises a more exhaustive investigation, 
and has devised a series of forks and organ pipes by which 
the complete series of musical notes between the limits of 
audition can be produced. As the employment of such a 
number of instruments in examining each case involves the 
expenditure of considerable time, their use must be confined 
to the investigation of particular cases, in which so exhaustive 
a test seems necessary. 

The value, as a diagnostic measure, of the next test to be 
applied depends upon the fact that, under normal conditions, 
sound waves impress the perceptive centres by the transmis- 
sion of the sonorous impulses to the labyrinth through the 
medium of the conducting mechanism — that is, through the 
external auditory meatus, the tympanic membrane, and the 
ossicular chain. As a matter of habit, all sounds are best 
perceived through this avenue, under normal conditions. If, 
however, the conducting mechanism is obstructed, be the ob- 

*Arch. fur Ohrenheilk., vol. xxx, p. 283. 



PLATE VII 




Bezold Continuous Tone Series. 



EXPLANATION OF PLATE VII. 

A ranges from d, 150 double vibrations per second, to a, 220 double vibra- 
tions per second. This fork undamped is c 1 , 256 double vibrations per second. 

H ranges from a, 220 double vibrations per second, to d\ 300 double vibra- 
tions per second. Undamped this fork is^- 1 , 396 double vibrations per second. 

B ranges from e 1 , 329 double vibrations per second, to a 1 , 440 double vibra- 
tions per second. Undamped this fork is c 2 , 512 double vibrations per second. 

I ranges from a 1 , 440 double vibrations per second, to d 2 , 600 double vibra- 
tions per second. Undamped this fork is^ 2 , 792 double vibrations per second. 

C ranges from e 2 , 659 double vibrations per second, to a 2 , 880 double vi- 
brations per second. Undamped this fork is c 3 , 1,024 double vibrations per 
second. 

J is an undamped fork, g 3 , 1,584 double vibrations per second. 

D is an undamped fork, c 4 , 2,048 double vibrations per second. 

K is an undamped fork, g 4 , 3,168 double vibrations per second. 

E is an undamped fork, c 5 , 4,096 double vibrations per second. 

G, Two closed organ-pipes, the larger having a tone range from c 2 , 512 
double vibrations per second, to a 3 , 1,760 double vibrations per second, and 
the smaller a tone range from a 3 , 1,760 double vibrations per second, to a 4 , 
3,520 double vibrations per second. 

L is an improved Edelmann-Galton whistle, having a tone range from 4,000 
double vibrations per second to 50,000 double vibrations per second. 

F, Hammer for striking forks. 

Note. — The most recent and complete set of instruments (Bezold and Edelmann, 
of Munich) consist of a series of ten clamped tuning forks, four undamped forks, 
two closed organ pipes and an improved Galton whistle. By means of the tuning 
forks a practically continuous tone series from 16 double vibrations per second to 
4,096 double vibrations per second may be secured. All the forks below g 3 are 
clamped, thus enabling the investigator to obtain a complete series of tones between 
16 double vibrations per second and 1,584 double vibrations per second. Above 
1,584 double vibrations per second the forks are undamped, thus giving a consider- 
ably wider range between the various instruments at this part of the musical scale. 
In the Edelmann series above described, the upper tone limit is determined by an 
improved Galton whistle, the instrument being modified so as to produce an abso- 
lutely pure sound even at the extreme upper limit of audition. 

(15° a) 



PLATE VIII. 








2 







Bezold Continuous Tone Series — Clamped Tuning Forks. 



EXPLANATION OF PLATE VIII. 

A ranges from C -2 , 16 double vibrations per second, to G -2 , 24 double 
vibrations per second. 

B ranges from G -2 , 24 double vibrations per second, to D _1 , 36 double 
vibrations per second. Undamped this fork gives the note of C, 64 double 
vibrations per second. 

C ranges from D~\ 36 double vibrations per second, to A -1 , 55 double 
vibrations per second. Undamped this fork sounds the note of G, 99 double 
vibrations per second. 

D ranges from A -1 , 55 double vibrations per second, to F, 90 double vibra- 
tions per second. This fork undamped is c, 128 double vibrations per second. 

E ranges from F, 90 double vibrations per second, to d, 1 50 double vibra- 
tions per second. Undamped this fork sounds the note of g, 198 double 
vibrations per second. 

(150 b) 



BONE CONDUCTION— WEBER'S TEST. 151 

struction in the canal, in the tympanic membrane, or within 
the middle ear itself, this path along which the sound waves 
normally pass is closed to a greater or less degree, depending 
upon the completeness of the obstruction. Under these con- 
ditions, the vibrations must reach the end organ of the audi- 
tory nerve by some other path, as, for example, the solid 
structures of the cranium ; and under these conditions a vi- 
brating body held in contact with the cranial bones produces 
a greater impression upon the auditory centres — that is, is 
heard more loudly — than when held in front of the external 
auditory meatus. It is to be remembered that under normal 
conditions also, when a sounding body is brought into con- 
tact with the bones of the skull, the vibrations are perceived. 
The period during which the sound is heard, however, is 
much less than the interval during which it is perceived 
when held before the auditory canal. Roughly speaking, the 
duration of air conduction is about double that of bone con- 
duction, the air conduction being relatively somewhat greater 
for the higher notes — that is, a little more than twice that of 
bone conduction — and the bone conduction, on the other 
hand, slightly greater for the lower notes of the scale, or a 
little more than half that of air conduction. Again, the very 
highest notes are scarcely heard by bone conduction under 
normal conditions, while the very low notes of the register 
are felt rather than heard, when the instrument producing 
them is brought in contact with the head. Age also influ- 
ences the power of bone conduction, wmich becomes much 
reduced after the age of forty-five or fifty years. 

Having learned the history of the malady, and determined 
the physical condition of the ear in the manner previously 
detailed, and having arrived at a conclusion concerning the 
extent of impairment by the functional examination, the next 
step should be to locate the pathological condition either 
in the sound-conducting or the sound-perceiving apparatus. 
Many of the methods employed for this purpose bear the 
names of the investigators who first demonstrated their value. 
The test most commonly spoken of is that of Weber, who, as 
the result of a series of investigations, found that when a vi- 
brating tuning fork was placed upon the skull in the antero- 
posterior vertical median plane and the meatus of one side 
was closed, the sound of the fork was heard more strongly in 
the ear which was occluded. In the same way if the struc- 



152 



FUNCTIONAL EXAMINATION. 



tures of the middle ear were bound down by adhesions, if the 
cavity was filled with fluid, or if the ligamentous tissues were 
so relaxed that the weight of the drum membrane and the 
attached ossicular chain constituted an obstruction to the 
passage of sonorous vibrations from the external canal to the 
parts beyond — under all of these conditions the vibrating tun- 
ing fork was heard better in the obstructed ear. The deduc- 
tion was inevitable that, in a case in which impairment of 
hearing existed upon one side alone, or in which impairment 
existed on both sides to an unequal degree, the perception of 
the tuning fork from the median line of the head would be 
stronger in the ear in which the pathological condition in the 
conducting mechanism was more marked. In other words, 
the fork would be better perceived by bone conduction in the 
poorer ear. If the organ upon one side was normal, the fact 
of the fork being heard better in this ear would locate the 
pathological condition of the opposite side in the perceptive 
rather than in the transmitting apparatus. 

The second classical test was devised by Rinne,* who was 
the first to determine that the normal ear perceived a vibrat- 
ing tuning fork, held before the canal, for about twice as long 
a time as when the shank of the fork rested upon the mastoid 
process. In cases where the canal was occluded, or where an 
obstructive lesion was present within the tympanum, it was 
found, after the fork had ceased to be heard in front of the 
ear, that its vibrations could still be recognized when the 
handle of the instrument was brought in contact with the 
mastoid. In applying this method of investigation then, if, in 
a given case in which the hearing is impaired, the duration of 
bone conduction is greater than that of air conduction, the in- 
ference would be that the impairment is due to some lesion 
of the conducting apparatus, and, pathological conditions of 
the canal being excluded by physical examination, the loca- 
tion of the morbid process must of necessity be the tympanic 
structures. If, on the other hand, the hearing is impaired 
and the normal relation between bone and air conduction is 
preserved, although both are found to be reduced, the seat 
of the disease must be the perceptive portion of the organ of 
hearing. 

While both of these facts are of undoubted value, the 

* Prager Vierteljahresschrift, 1855, vol. i, p. 71, vol. ii, pp. 45-155. 



RINNE'S TEST. 1 53 

accumulation of clinical evidence from the investigation of a 
large number of cases, has convinced those interested in Otol- 
ogy that in many instances they can not rely absolutely upon 
these reactions to indicate the site of the lesion. 

The first fact with which we are impressed in a careful 
reading of these experiments is that very little attention seems 
to have been paid to the pitch of the fork used in conducting 
the tests. From what we know by experiment (see Physi- 
ology) of the effects of increase of tension in the intratympanic 
structures, or the weighting of these parts or of the tympanic 
membrane, it can easily be seen that if the impairment of 
hearing is very slight and the fork used in making the test is 
of moderately high pitch, an absolute reversal of the relation 
between the bone and air conduction may not take place, 
since the application of a load to the drum membrane or 
ossicles interferes principally with their vibration in their re- 
sponse to the lower notes of the scale. This fact is recog- 
nized by Lucas and by Bezold,* the latter restricting the ap- 
plicability of Rinne's experiment to those cases in which the 
whispered voice is not understood at a distance greater than 
three and a half feet. It must be remembered, that in arriv- 
ing at this conclusion regarding the application of Rinne's 
test, a tuning fork making about 512 V. D. was used. By the 
use of forks of lower pitch the test becomes applicable to cases 
in which the degree of impairment is much less than this. 
It is seldom wise, however, to determine bone conduction 
with a fork of lower pitch than 128 V. D., since a fork lower 
than this is felt rather than heard, and comparatively few 
patients are able to distinguish between the two sensations. 
If a fork making 512 V. D. is used in cases where the impair- 
ment is slight, instead of looking for an absolute reversal of 
the relation between bone and air conduction, a comparison 
should be made between the time during which the fork is 
heard when held in front of the canal and that during which 
it is perceived when placed upon the mastoid. It will be 
found that bone conduction is increased relatively, although 
Rinne's test will be positive. Such a result is called " a di- 
minished positive." For clinical purposes, however, it would 
be impossible to conduct the test in this manner, as the dura- 
tion periods would then need to be determined with great 

* Allg. Wien. med. Ztg., 1SS7, p. 1S3. 



154 FUNCTIONAL EXAMINATION. 

exactness, and reliable results could be obtained only by 
complicated apparatus. 

Following in this same line, Schwabach * has found that 
where obstruction exists in the conducting mechanism, the 
absolute period of bone conduction exceeds that of the 
normal ear. Pomeroy,f in applying this test insists upon the 
ears being tightly stopped with the fingers. In other words, 
he compares the maximum bone conduction to be obtained 
from the normal ear with that to be elicited from the organ 
under examination, combining really the test of Schwabach 
with that of Weber. 

The determination of the absolute bone conduction in sec- 
onds, not only consumes considerable time, but the result 
obtained must vary with the age of the patient, and with dif- 
ferent examiners. The variations in the force of the blow 
setting the fork in vibration also constitute a source of error. 
It is much simpler, if the examiner possesses a normal ear, to 
follow the plan suggested by Gardiner Brown,J who con- 
ducts the test as follows: The tuning fork is set in vibration, 
and the handle is held against the mastoid of the patient 
until the sound is no longer heard, this fact being communi- 
cated to the examiner by the patient raising his hand. The 
handle of the fork is then applied to the mastoid of the ex- 
aminer, and if he perceives the sound, it is fair to assume that 
the bone conduction of the patient is below the normal stand- 
ard. If, on the contrary, he no longers hears it, the inference 
is that the bone conduction is normal. For general purposes, 
the data obtained in this manner are sufficiently exact, when 
taken in connection with results arrived at by applying the 
other tests for determining the location of the lesion. 

Reviewing briefly the facts stated in the preceding pages, 
it will be seen that lesions of the conducting mechanism are 
characterized by — 

I. A loss or impairment of audition for the lower notes 
of the scale, and as the degree of impairment of hearing in- 
creases, the lowest note which can be perceived, or the lower 
tone limit, as it is called, becomes elevated. 

II. The relative duration of bone conduction as compared 



* Zeitschrift fiir Ohrenheilkunde, vol. xiv. 

f Diseases of the Ear, New York, 1883, p. 337. 

X Lennox Browne, The Throat and its Diseases, London, 1S87, p. 535. 



DIFFERENTIAL DIAGNOSIS. 1 55 

with air conduction increases, the inversion of the ratio being 
more marked for the lower notes of the scale and affecting 
these first, the change occurring with the higher notes in 
proportion as the pathological condition increases, and conse- 
quently as the impairment of function becomes more marked. 

III. Lesions of the conducting apparatus interfere very 
slightly with the perception of the highest notes of the scale 
by air conduction — in other words, have very little effect upon 
the upper tone limit. 

In the same manner diseases of the receptive mechanism 
are characterized by — 

I. No elevation of the lower tone limit. 

II. No change in the normal relation between the duration 
of bone conduction as compared with air conduction, the 
absolute duration of both, however, being reduced. 

III. Absolute deafness for certain notes of the scale, 
usually in its upper portion, thus frequently lowering the 
upper tone limit. This is almost invariably the case when 
the condition is secondary to changes within the tympanum. 

Our plan of functional examination, then, is essentially as 
follows : 

The quantitative determination of the hearing by means of; 

a. The watch, if the impairment is slight. 

b. The acoumeter, if the degree of impairment is more 
marked. 

c. The determination of the hearing distance by means of 
the " forced whisper " by making use of numbers of two 
figures. 

The qualitative determination of the hearing : 

a. The determination of the lower tone limit, using for 
this purpose the fork already described, illustrated in Fig. 61. 
The record shows the lowest number of vibrations perceived 
by the patient as a musical note, the different rates of oscilla- 
tion being obtained by changing the position of the clamps 
as already explained. 

b. The determination of the upper tone limit by means 
of the Galton whistle, recording the highest number of vibra- 
tions perceived by the patient as a musical sound. 

c. The determination of absolute bone conduction. 

In determining the absolute bone conduction in anv given 
case the rate of vibration of the tuning fork, as has already 
been stated, must be taken into account. In patients under 



I5 5 FUNCTIONAL EXAMINATION. 

forty years of age the most convenient fork to be employed 
is one tuned to the note " C," making five hundred and twelve 
double vibrations per second. In patients over forty, a fork 
making two hundred and fifty-six double vibrations per second 
gives the most accurate results. For the benefit of those who 
do not care to make a special study of aural diseases, and 
hence to whom a multiplicity of devices for determining the 
actual functional condition of the ear is rather objectionable, 
it may be well to enumerate the instruments with which satis- 
factory work can be done. 

In the first place, it is necessary to be provided with a low- 
pitched tuning fork, such as the one shown in Fig. 61, fitted 
with clamps, by means of which the rate of vibration can be 
changed by altering their position upon the limbs of the fork. 
The highest note obtainable with this instrument is one of 
sixty-four vibrations per second. This instrument will enable 
the observer to determine defects in the transmission of the 
lower notes of the scale, a condition which is characteristic of 
the lesions of the conducting apparatus. It may not be possi- 
ble for him to determine the lower tone limit, as it may lie 
above the highest note obtainable with this fork ; but if the 
lower tone limit lies above 64 V.D., the inference must be 
that the sound-conducting apparatus is not in a normal con- 
dition. For the determination of the upper tone limit the 
observer must be provided with a Galton whistle. The modi- 
fied form, devised by the author and shown in Fig. 62, gives 
a greater range than the original instrument of Galton, and is 




FlG. 62. — The author's modification of the 
Galton whistle. 

preferable when only a limited number of tuning forks are 
at hand. This whistle enables tests to be made through a 
compass of from about sixteen hundred and seventy-seven vi- 
brations per second to about forty thousand vibrations per 
second, the increased length of the instrument augmenting 
the compass ; it thus supplies the place of the higher tuning 

forks. 

For the determination of bone conduction, if but one in- 
strument is to be used, the C fork, making 512 V. D., is the 



INSTRUMENTS. 



157 



rjest for general use, since its construction is comparatively 
simple, and overtones interfere but little with its primary 
note. The instrument (Fig. 63) devised by Blake, and mak- 
ing 256 V. D., is also exceedingly well adapted to this pur- 
pose. In this fork the overtones are avoided by increasing 
the weight of the branches at their free ex- 
tremities. With these three instruments a 
fairly accurate functional examination can 
be made, and the deductions drawn from 
the data thus obtained will scarcely ever be 
misleading. A more extended examination 
will simply confirm, in most instances, the 
opinion already formed as the result of the 
investigation with the above limited num- 
ber of instruments. It is of advantage, of 
course, to have appliances at hand for the 
production of all the notes of the musical 
scale, and Bezold * has devised a series of 
tuning forks and of wind instruments which 
produce musical notes on the principle of 
a closed organ pipe, and by which the in- 
vestigator can obtain any note of the scale 
between the high and low limits of audition. 
The series consists of eight tuning forks, 
two organ pipes, and one Galton whistle. 
Even for a very exhaustive investigation 
of any case it is scarcely necessary to multiply the arma- 
mentarium to this extent, since by means of the low fork 
already mentioned, together with the modified Galton whistle 
and the series of five forks recommended by Hartmann f (Fig. 
64), perfectly satisfactory work can be done. 

Each of the five forks in this set is tuned to the note C ; 
the lowest fork making one hundred and twenty-eight vibra- 
tions per second, while the highest registers two thousand 
and forty-eight vibrations per second, each fork being tuned 
an octave higher than the one below it. This particular range 
is chosen as it includes those fundamental notes which may 
be called essential to perfect audition — that is, the range of 
notes employed in ordinary conversation. In addition, the 



Fig. 63. — Blake's tun- 
ing fork. The rate 
of vibration indi- 
cated on the handle 
(512) refers to single 
vibrations. 



* Archiv fiir Ohrenheilk., vol. xxx, p. 2S3. 
\ Krank. des Ohres, Berlin, 1SS9, p. 32. 



58 



FUNCTIONAL EXAMINATION. 




Fig. 64. — Hartmann's series of tuning forks. 



Galton whistle will enable an investigation as to the power 
of the patient to perceive those notes of the scale lying above 

the highest fork of the 
Hartmann series. I have 
employed these instru- 
ments for some time, and 
have seldom been misled 
in the deductions made 
from the results thus ob- 
tained. 

In making these quali- 
tative tests certain pre- 
cautionary measures are 
necessary : for example, 
to avoid the production 
of overtones in using the 
large tuning fork with 
the clamps so placed as 
to produce the lowest 
obtainable rate of vibra- 
tion — that is, twenty-six vibrations per second. If care is 
not taken, an overtone will be produced when the fork is 
struck, and this may be perceived by the patient to the ex- 
clusion of the very low primary note of the fork. In every 
instance, therefore, the observer should make certain by hold- 
ing the vibrating fork for a moment before his own ear be- 
fore it is used to test the patient, that the primary note alone 
is elicited. It must also be remembered in testing air con- 
duction with tuning forks, that the fork may be held in front 
of the ear in such position, that its note will not be perceived, 
on account of the interference of the sound waves, which 
completely neutralize each other and cause absolute silence. 
This phenomenon depends entirely upon certain physical 
facts, as pointed out long ago by Weber.* That this inter- 
ference may take place the fork is held so that either of the 
four angles of the parallelogram inclosed by the branches 
is directed toward the meatus. During the complete rota- 
tion of the fork upon its long axis, therefore, there will be 
four periods during which the note is heard, alternating with 
four periods of complete silence. It is hardly necessary co 



Die Wellenlehre, Leipzig, 1825, p. 506. 



PRECAUTIONARY MEASURES. I 59 

say, in conducting the functional examination, that care must 
in any case be exercised that each of these positions is avoided. 
Urbantschitsch * has also demonstrated that when the vibrat- 
ing fork is carried toward the ear from before backward it is 
not heard as it passes the anterior and posterior margins of 
the meatus, and the same phenomenon is observed as it passes 
the superior and inferior boundaries of the meatus, if carried 
from above downward. 

In testing absolute bone conduction it often happens that 
the patient confuses the feeling of vibration communicated by 
the instrument to the cranial bones with the perception of the 
tone which it produces. This is particularly true when forks 
of low pitch are employed in making tests, and in cases of al- 
most absolute deafness. The first error can be avoided by 
using a fork of higher pitch, the second by bringing the vibrat- 
ing fork in contact with some other portion of the body, as, 
for instance, by pressing the handle upon the elbow or knee, 
and questioning the patient as to whether the sensation is ex- 
actly the same as when the instrument is applied to different 
parts of the cranium. If it is, it naturally follows that he has 
confused the tactile sensibility with the auditory sense, and 
his statements are consequently unreliable. 

It should also be remembered that the feeling of vibration 
is much more marked when the handle of the fork is slender 
than when it is of considerable thickness, and this should be 
borne in mind in selecting an instrument for testing bone 
conduction. 

In using the Galton whistle the instrument is held close 
to the entrance of the canal and the current of air is so regu- 
lated as to produce the most perfect musical note obtainable 
with the scale in any given position. Here the individual 
tested may not distinguish between the blowing sound pro- 
duced by the air and the high-pitched musical note which he 
should hear. If the length of the tube is increased so that a 
distinct whistle is at first heard and then gradually reduced 
by advancing the obturator by turning the screw, thus pro- 
ducing notes successively higher in pitch, he will easily dis- 
tinguish the point at which the whistling sound disappears 
and the blowing or puffing sound is heard. If the screw is 
then turned in the opposite direction until the whistling 

* Lehrb. der Ohrenheilk., Vienna, 1S90, p. 37. 



ioo FUNCTIONAL EXAMINATION. 

sound is again perceived, a reading- of the scale will give the 
true upper tone limit. Further, the patient should be made 
to describe the character of the sound in his own words and 
without any suggestion on the part of the surgeon, as the 
latter can easily infer from the reply, whether the impression 
is that of a musical note or simply the blowing due to the 
current of air. 

It would seem, therefore, a matter of no great difficulty to 
make a fairly accurate differentiation between diseases of the 
sound-conducting and sound perceiving-apparatus. We meet 
with a large class of cases, however, in which both portions 
of the auditory organ are at fault, the perceptive apparatus 
being secondarily affected as the result of pathological condi- 
tions in the sound-conducting mechanism. Here, then, the 
results obtained by the above tests may be confusing. In 
order, therefore, to interpret correctly the data obtained from 
such an examination, it is necessary to inquire somewhat 
closely into the causes which are operative in the production 
of the phenomena already described. 

It is conceded that the augmentation of bone conduction 
in pathological conditions of the meatus and middle ear which 
cause an obstruction to the passage of sonorous waves inward, 
is due to the fact that it prevents the passage of undulations out- 
ward from the ear when the vibrating body is brought in con- 
tact with the cranial bones in the same manner as it offers a 
barrier to their propagation in the opposite direction when the 
source of sound is held near the meatus. Steinbruegge * con- 
siders that the absolute or relative increase in the bone con- 
duction in these cases is due to a condition of hyperassthesia 
of the auditory nerve resulting from the mechanical irritation 
to which its terminal fibres are subjected. While this condi- 
tion of increased irritability may be present in many cases, it 
is certainly not the cause of the increased bone conduction 
in most instances, other symptoms of auditory hypersensitive- 
ness being wanting in many cases. Further, an examination 
of the condition of the auditory nerve by means of the gal- 
vanic current fails to support Steinbruegge's hypothesis. 

Gradenigof has shown that lesions of the conducting ap- 
paratus do in some instances cause the auditory nerve to re- 



* Archives of Otology, vol. xvii, p. 117. 
} Arch, fur Ohrenheilk., vol. xxvii, p. 1. 



IRREGULAR PHENOMENA. l6l 

spond more easily to the galvanic current than under normal 
conditions ; and this fact should be remembered, as it enables 
us to interpret results, which would otherwise seem contra- 
dictory, obtained by functional examinations in certain cases. 

The experiments of Siebenmann* demonstrate that an 
increase in the labyrinthine pressure prolongs bone conduc- 
tion, as evidenced by an examination before and after Val- 
salva's inflation (the latter procedure, as is well known, in- 
creasing the tension of the labyrinthine fluid). In cases 
where the membrana tympani had been destroyed the laby- 
rinthine pressure was increased by pressing the head of the 
stapes inward by means of a probe. 

We should expect, therefore, to find a prolongation of the 
interval during which the tuning fork is heard when brought 
in contact with the cranial bones, in all cases where speculum 
examination shows either a depressed drum membrane, or the 
presence of adhesions within the tympanum, drawing the 
ossicular chain toward the inner tympanic wall. This is usu- 
ally the case, but occasionally we find that the reverse is 
true. The latter condition can be explained upon the hy- 
pothesis that the condition of increased tension has lasted so 
long that the function of the auditory nerve has been, to a 
certain extent, ablated by the mechanical pressure, and that 
the case is no longer one of intratympanic disease pure and 
simple, but that an actual pathological condition is present 
within the labyrinth, dependent upon the disturbance within 
the middle ear. 

When the intratympanic changes are comparatively sud- 
den, as in cases of simple congestion and oedema of the 
Eustachian tube with displacement of the drum membrane 
and of the entire ossicular chain inward, we observe that, in 
addition to an augmentation of bone conduction, the upper 
tone limit is usually considerably lowered. This is easily 
explainable when we remember that the highest notes of the 
scale are perceived by the lowest portion of the cochlea. 
This portion of the labyrinth, lying as it does in immediate 
relation to the foot plate of the stapes and the membrane of 
the round window, will be easily affected not only by changes 
in the position of the base of the stapes and of the membrana 
tympani secondaria, but also by circulatory disturbances 

* Arch, of Otol., vol. xxii, p. i. 



1 62 FUNCTIONAL EXAMINATION. 

within the tympanum. It is not strange, therefore, that the 
very highest notes of the scale should be no longer heard 
when any sudden change of position takes place in the ossi- 
cular chain, or when the tympanic mucous membrane be- 
comes engorged with blood, interfering with the motility of 
the ossicles. If the interference with the function of the 
cochlea depends simply upon a slowly increasing pressure, 
the equilibrium of the labyrinth is but slightly disturbed, 
owing to the direct communication of both the endolymphic 
and perilymphic spaces with the lymph channels within the 
cranial cavity. In such cases, therefore, very little disturb- 
ance of the upper tone limit is observed, although the intra- 
tympanic structures may be completely bound down by adhe- 
sions and drawn inward toward the external labyrinthine 
wall. The channels of communication, however, between 
the labyrinthine and intracranial lymphatic spaces are so 
narrow, that any sudden increase of pressure causes a dis- 
turbance of equilibrium in the labyrinthine fluid, and hence 
lowers the upper tone limit. It is wise, in view of this inti- 
mate association between the labyrinth and the tympanum, 
to repeat the qualitative tests after a restoration of the nor- 
mal air pressure within the tympanum by inflation, to guard 
against all possibility of error. 

In addition to the tests given above, mention should be 
made of certain other methods of investigation which lie at 
our disposal in making a differential diagnosis. Among the 
most important of these are the following : 

Bings* Experiment. — This test, first described by the 
above-named author, is essentially a modification of Weber's 
experiment. It is conducted as follows : A vibrating tuning 
fork is applied either to the forehead or vertex in the median 
line, and is held in this position until its note is no longer 
perceived. If at this moment the finger is inserted into the 
external auditory canal of either side, the note of the fork 
will again be heard. This second interval during which the 
fork is perceived is called the period of secondary perception 
for the tone. If the conducting apparatus is normal this sec- 
ondary perception interval is well marked ; while if its dura- 
tion is shortened, the presence of some obstructive lesion of 
the conducting mechanism may be inferred. If the interval 

* Wien. med. Blatter, 1891, No. 41 



GELLE'S TEST. 163 

of secondary perception is of normal duration, while at the 
same time there is an interference with the auditory appara- 
tus, as evidenced by subjective or objective symptoms, the 
conducting mechanism must be in a normal condition, and 
the seat of the morbid process must lie within the labyrinth in 
the auditory nerve or be due to changes within the cerebral 
hemispheres or medulla. 

Gelle's Test. — Gelle * proposes to test the mobility of the 
ossicular chain, and especially of the stapes, by compressing 
the air in the external auditory meatus and observing the 
effect upon the perception of the note of a tuning fork in con- 
tact with the skull. If the foot plate of the stapes is movable, 
with each condensation of air within the meatus the sound of 
the fork becomes much diminished in intensity or may be lost, 
reappearing again as the pressure is relieved. The condensa- 
tion is effected by means of a small air bag provided with a 
flexible rubber tube, the free extremity of which carries a 
conical tip which can be inserted air-tight into the canal. If 
the labyrinth is affected, either primarily or secondarily, the 
tone will also be diminished, but the increase in pressure will 
produce a sense of dizziness and sometimes tinnitus. 

Rohrerf considers this test valuable when taken in con- 
nection with Rinne's test. According to his investigations, 
when Rinne's experiment was negative Gelle's test yielded a 
negative result in seventy-three per cent of the cases tested 
and a positive result in but twenty-three per cent. When 
Rinne's test was positive Gelle's test yielded negative results 
in twelve per cent and positive results in eighty-eight per 
cent of the cases examined. 

The patients selected in these experiments of Rohrer's 
were cases in which the hearing was very much impaired — so 
much, in fact, as to make it more than probable that a laby- 
rinthine lesion co-existed with the pathological process within 
the tympanum. Rohrer lays particular stress upon the value 
of Gelle's experiment in determining the secondary involve- 
ment of the labyrinth following an inflammatory process 
within the middle ear, in which case Rinne's test very fre- 
quently yields negative results ; if Gelle's test gives negative 
results as well, the inference that the labyrinth is affected is 



* Tribune medical, Oct. 23, 1SS1. 

\ Lehrb. der Ohrenheilk., Vienna, 1S91, p. 66. 



164 FUNCTIONAL EXAMINATION. 

fully warranted. In cases where the hearing is very much 
impaired, and Rinne's test is positive, Gelle's test is also 
usually positive, if the labyrinth is affected. 

Eitelbergs Test. — Another experiment, calculated to differen- 
tiate between lesions of the labyrinth and those of the middle 
ear, is that of Eitelberg.* It depends upon the principle that 
a nerve continuously irritated by any one stimulus becomes 
fatigued after a certain time and performs its function less 
readily. It follows, therefore, that when the perceptive tract 
is in an abnormal condition this effect will be produced more 
readily than in a state of perfect health. In performing the 
test a large tuning fork is made to vibrate in front of the ear 
for a period of fifteen or twenty minutes, the instrument be- 
ing set in vibration repeatedly by as nearly as possible the 
same initial force as soon as its oscillations become weak. If 
after the nerve has been subjected to this continuous stimulus 
the perception interval has not been much shortened, the re- 
ceptive apparatus is assumed to be in a normal condition. As 
the value of this test depends greatly upon the intelligence 
of the patient, its application is somewhat limited. A much 
simpler demonstration of auditory fatigue is constantly pre- 
sented, in cases where prolonged testing with sounds which 
are of a similar character as, for instance, the watch, acoumeter, 
or the whisper yield results which differ greatly from each 
other, and the ability to perceive the sound steadily decreases 
as the patient becomes fatigued. We often note a similar con- 
dition of the nerve in what may be termed the persistence of 
an auditory impression ; for instance, in testing a patient with 
the watch it will often be stated that the sound is heard either 
after the watch has been stopped or has been removed to such 
a distance that it is impossible for the sound to be heard- 
This depends upon the fact that an impression once made 
upon the auditory centres is retained by them for a longer 
period than normal, demonstrating the fact that they are no 
longer in a state of health. 

Gradenigo s Test. — Gradenigo f finds in cases in which the 
acoustic nerve-trunk is affected that it quickly loses its power 
of reacting to sonorous stimuli if the quality of the sound 
remains unchanged. In other words, the nerve is quickly 



* Wien. med. Presse, 1887, No. 10. 

f Handbuch der Ohrenheilk. Von Schwartze, Leipzig, 1893, vol. ii, p. 403. 



GRADENIGO'S TEST. 



65 



fatigued. If, however, it is allowed to rest for a short time, 
it is again able to perform its function. The simplest method 
of practicing this test is by the use of a tuning fork of about 
fifteen hundred or two thousand vibrations per second as the 
source of sound. Such a fork is perceived from fifty to sev- 
enty seconds under normal conditions. In cases of torpidity 
of the auditory nerve, if this fork is set in vibration and held 
close to the ear its note ceases to be audible after a much 
shorter interval. If it is now removed a short distance from 
the ear, for a few seconds, and again carried close to the 
meatus, it will be again perceived. This manoeuvre may be 
repeated several times during one period of vibration of the 
fork. It seems that the auditory nerve when in this condition 
is easily fatigued, but after an interval of rest it may react 
to a weaker stimulus than that which failed to excite it after 
it had been subjected to that one for a certain time. 

Gradenigo * asserts that when the auditory nerve trunk is 
involved the interference with function is particularly marked 
for the tones of the middle portion of the scale, the very high 
and very low tones being well perceived. 

In all of these tests, dependence must be placed upon the 
statements of the patient, and much of the accuracy must de- 
pend upon the intelligence and the correctness with which 
he answers questions. Methods have been devised to avoid 
the necessity of introducing this element of error in deter- 
mining the location of the morbid process. Thus Lucaef 
conducted an exhaustive series of experiments with an instru- 
ment which he termed the interference otoscope. The device 
consisted of a tuning fork, the vibrations of which were main- 
tained at a constant amplitude by the action of the electric 
current. The fork was placed so that its vibrations were 
collected by a funnel-shaped receiver, the smaller end of 
which was prolonged as a flexible tube terminating in three 
branches. One of these terminal divisions was inserted into 
each external auditory meatus of the patient, while the third 
was inserted into either auditory canal of the examiner. It is 
thus seen that the vibrations of the fork would be conveyed 
through the tubes to both ears of the patient and to the ear 
of the examiner as well. Any obstruction in the sound-con- 



* Op. cit., p. 395. 

f Arch, fur Ohrenheilk., vol. iii, p. 1S6. 



1 66 FUNCTIONAL EXAMINATION. 

ducting apparatus, as we know, renders the transmission of 
vibratory impulses more difficult in proportion to the degree 
of obstruction, and, as the sound perceived by the examiner 
represents not only the vibrations coming directly to his ear 
— from the fork — but also the waves reflected from the ears 
of the patient, it would be possible, by alternately closing 
the tubes upon the one side and the other, to estimate any 
variation in the intensity of the sound thus produced. It is 
evident that the sound would be more intense in proportion 
as the transmitting mechanism offered an obstruction to the 
inward progress of the impulses. In other words, the more 
intense sound should come from the poorer ear if the conduct- 
ing apparatus alone were affected. Great care must be taken, 
in conducting this test, that the tubes of the binaural stetho- 
scope shall be exactly equal in length, and also that the ear- 
pieces shall fit the meatus exactly, in order that all of the 
reflected waves may pass backward through the tube and into 
the ear of the examiner. This test has been somewhat modi- 
fied by Jankau * in the following manner : 

A vibrating tuning fork is placed upon the vertex of the 
patient and the receiver is dispensed with, while the auscul- 
tation tube of the examiner terminates in a Y tube, the free 
extremities of which join the tubes occluding the external 
canals of the patient as in the other instrument. Under these 
conditions the tone conveyed to the ear of the examiner is 
re-enforced by the action of the external meatus, which acts 
as a resonator, augmenting the sound of the fork. Under" 
normal conditions, both ears being the same, there is no ob- 
struction to the vibrations through the cranial bones to the 
labyrinthine fluid, from which they are communicated to the 
ossicular chain, to the membrana tympani, and in turn to the 
air in the canal, which re-enforces the sound bv its action as 
a resonator. If, however, an obstruction, due to an increased 
tension of the labyrinthine fluid, exists, which prevents the 
passage of the sound waves outward from the labyrinth to 
the ossicular chain, this resonant action will to an extent be 
diminished, and the observer will perceive that the sound 
from this side is less intense. In other words, the weaker 
sound will come from the poorer ear, if the impairment of 
function is due to increased labyrinthine tension. If, on the 

* Arch, fur Ohrenheilk., vol. xxxiv, p. 190. 



GALVANIC REACTION. 167 

other hand, the vibrations of the labyrinthine fluid are not 
impeded, but the tympanic structures external to the stapes 
are in a state of increased tension, the resonant action of the 
canal will be increased on account of the rigidity of its walls, 
the condition favoring a more perfect reflection of the sound 
waves ; in which case the stronger tone will come from the 
poorer ear. Jankau's clinical investigations and experiments 
seem to confirm this supposition. 

The difficulty of avoiding errors of experiment are so con- 
siderable here that the chief use of the procedure will be as a 
confirmatory test. 

The Galvanic Reaction of the Auditory Nerve. — As has been 
stated, the auditory nerve differs very little from other spe- 
cial or general structures of a similar nature. In the study 
of nervous diseases in general, great attention has been paid 
to the reactions of nerve tissue under electrical stimulation, 
and the changes in the electrical phenomena which morbid 
processes cause. Special attention was given by Brenner * 
to the effect produced by the galvanic current upon the audi- 
tory nerve, and he was the first to formulate the reaction of 
the normal acoustic nerve. According to this author, upon 
the application of the galvanic current, a sharp sound is pro- 
duced at the moment of cathodal closure (c. a), which, as the 
current is continued, is transformed into a continuous sing- 
ing sound (c. d.). At the moment of cathodal opening (c. o.) 
the singing ceases abruptly. Anodal closure (a. c.) produces 
no sound, and the period of silence is continued as long as 
the • current passes in this direction (a. d.). Upon anodal 
opening (a. o.) a low sound is perceived similar in quality to 
that heard at cathodal closure, but of less intensity. The 
strength of the current in milliamperes represents the strength 
of the current necessary to excite the acoustic nerve. If after 
cathodal closure the current is allowed to pass for a few sec- 
onds and the circuit is then broken, it will be found that a 
current of less intensity is necessary to excite an auditor y im- 
pression than in the first instance. The same follows if the 
experiment is repeated for the third time. These variations in 
the strength of the current represent the primary, secondary, 
and tertiary electric irritability of the auditory nerve. Under 

* Untersuch. u. Beobachtungen iiber die Wirkung elektrischer Strome auf das Ge- 
hororgan, Leipzig, 1S6S. 



l6S FUNCTIONAL EXAMINATION. 

ordinary conditions, the nerve requires so strong a current to 
produce an auditory impression upon it, as to make it neces- 
sary to conclude the experiment before the reaction is ob- 
tained, on account of the pain which the passage of the cur- 
rent causes. The primary irritability, however, should not 
fall below six milliamperes. In conditions of hyperaesthesia 
the primary irritability will be found much below this figure ; 
while in cases of torpidity of the nerve this normal limit is 
exceeded. 

In the absence of a large galvanic battery, a simple storage 
battery of from four to eight volts furnishes sufficient current 
to enable one to make all of these tests ; it is necessary to com- 
bine in the circuit a reliable rheostat and a milliampere-metre. 
The current obtained in this manner, while not of great 
strength, is ample for the purpose and possesses the advan- 
tage of not being liable to the variations in intensity which we 
so often find when the dip cell is used. 

Some of the dry cells now offered for sale also furnish a 
convenient means for securing a reliable current with the ex- 
penditure of but a trifle. Twelve dry cells furnish a current 
sufficient for taking the galvanic reactions of the auditory 
nerve. In no instance should the ear be subjected to the 
action of the electric current for purposes of either diagnosis 
or therapeusis without including a rheostat in the circuit, by 
which its intensity can be controlled. In employing the gal- 
vanic current as a means of diagnosis it is also essential that 
a milliampere-metre be added to estimate quantitatively, the 
current causing special phenomena. 

Considerable difference of opinion exists as to the proper 
method of applying the electrodes in conducting the tests. 
According to the choice of the examiner, the electrode applied 
to the ear may be placed either upon the side of the face just in 
front of the tragus, or it may be placed over the entrance of the 
canal, which has been filled with water ; or the canal may be 
filled with water and the electrode immersed in this, care be- 
ing taken that it is insulated, so as not to come in contact with 
the walls of the meatus. The circuit is completed by means 
of a broad electrode placed upon an indifferent region, some- 
times on the back of the neck and sometimes held in the hand. 

The experiments of Gradenigo * are of considerable in- 

* Arch, fur Ohrenheilk., vol. xxvii, p. I. 



GALVANIC REACTION. 169 

terest, in that they demonstrate not only the reaction of the 
acoustic nerve to electrical stimuli, but also seem to prove con- 
clusively that auditory hyperassthesia is not the cause of the 
lateralization of the tuning fork in affections of the middle ear. 
The investigations of this writer show that while the sound 
may be referred to the hyperassthetic side, it is often lateralized 
when no hyperassthesia exists, or the sound may be referred 
to one side even when hyperassthesia exists upon the other. 

Another interesting result demonstrated by these experi- 
ments is the fact that electric stimulation of the nerve of one 
side often increases the susceptibility of the opposite nerve to 
the action of the current. 

The remarks made concerning the electric acoumeter ap- 
plies to the employment of the galvanic tests — viz., that al- 
though valuable, the method is too complicated to admit of 
general use, and the amount of additional information gained 
by it scarcely compensates for the extra time required for its 
application. We shall therefore rely principally upon the 
power of audition for lower notes, the hearing power for high 
notes, the absolute bone conduction and a quantitative deter- 
mination of the integrity of audition by means of the whis- 
per, in arriving at an opinion concerning the location of any 
lesion. To these may properly be added either Eitelberg's 
test or that of Gradenigo, to afford information concerning the 
ease with which the nervous apparatus becomes exhausted by 
prolonged stimulation as compared with the normal organ 
under similar conditions. The data furnished by these latter 
tests, however, may be frequently quite as well obtained by 
observing closely the behavior of the patient during a pro- 
longed functional examination. When the perceptive appa- 
ratus is in an asthenic condition, it will be found that pro- 
longed qualitative and quantitative tests are followed bv a 
marked diminution in the ability of the patient to perceive a 
given sound, demonstrating very clearly that the continuous 
stimulation to which the nerve tissues have been subjected, 
has ablated their power to a marked extent. 

It should be remembered that under normal conditions 
excitation of the perceptive tract renders it more sensitive in 
responding to stimuli, as is clearly shown bv the experiments 
of Urbantschitsch.* The statement already made in consider- 



* Archiv fiir Ohrenheilk., vol. xxxiii, p. 1S6. 



I 7 o FUNCTIONAL EXAMINATION. 

ing the electrical irritability of the auditory nerve is no less 
true of the response of the nerve structures to sonorous 
stimuli — that is, a sounding body allowed to vibrate before 
one ear may, to a marked degree, influence the perceptive 
power of the organ on the opposite side.* 

* Urbantschitsch, Lehrbuch der Ohrenheilkunde, Vienna, 1890, p. 417. 






SECTION II. 

DISEASES OF THE CONDUCTING APPARATUS. 




Fig. 640. — Congenital asymmetry and deformity of auricle. 
(172) 



DISEASES OF 
THE CONDUCTING APPARATUS. 



I. DISEASES OF THE AURICLE. 
CHAPTER V. 

CONGENITAL MALFORMATIONS OF THE AURICLE. 

Any malformation of the external ear at birth has for a 
long time been considered somewhat indicative of the pres- 
ence of some corresponding mental impairment. That mental 
weakness, defects, or perversions often accompany such anom- 
alous anatomical conditions is a matter of experience ; that the 
two always occur together, however, is by no means true. 

Concerning the classification of these malformations we can 
divide them into : 

I. Deformities of particular parts of the auricle, the exter- 
nal ear as a whole maintaining its general outline. 

II. An anomalous shape or a malposition of the entire 
auricle, including variations in size, or in the angle of attach- 
ment to the skull. 

III. The presence of some anomalous anatomical condi- 
tion, such as certain supernumerary appendages, fistulae, etc., 
in the region of the ear, the auricle being present either in its 
normal form or being more or less altered in shape. 

IV. A condition of asymmetry between the organs of the 
opposite sides. 

Since the last group is of but little importance, it may be 
disposed of in a few words. Occasionally we find one auricle 
either very large, or, on the other hand, while normal in con- 
tour, uniformly reduced in size without any other departure 
from the normal standard. Such a condition can be looked 
upon only as a " freak of Nature," and is in no way associated 
with mental impairment, nor can any definite cause be as- 
signed for its existence in many cases. When met with in 
13 (173) 



Ij4 CONGENITAL MALFORMATIONS OF THE AURICLE. 

the adult, a careful investigation of the previous history may 
reveal some injury in childhood which had been forgotten, 
and the deformity, which at first was considered congenital, 
really depends upon a traumatic cause. 

I. Deformities of particular parts of the auricle, the ex- 
ternal ear as a whole maintaining its general outline. 

Anomalies of the Helix. — The so-called Darwinian ear and 
the satyr ear are examples of moderate anomalies of this 
character. Wagenhauser * has reported an instance in which 
the upper part of the helix was absent on both sides, while 
Stetter \ and Schubert £ have reported instances in which 
the helix was abnormally developed, hanging downward and 
forward as a flap. In Stetter's case the antihelix was also in- 
volved, and the deformity was so extensive as to obstruct the 
entrance to the meatus. Relief was obtained by a plastic 
operation. 

Anomalies of 'the Antihelix. — When the antihelix is strong- 
ly developed it may project beyond the line of the helix to 
such an extent as to constitute a deformity. This is most 
noticeable when the auricle is viewed from behind. Grade- 
nigo has observed this condition more frequently in females 
than in males, and considers it more common among the 
criminal and insane than among others. In a case observed 
by the author the antihelix projected fully one eighth of an 
inch above the plane of the helix, and a condition of asym- 
metry was also present, the anomalous condition being partic- 
ularly well marked upon the left side ; upon this side also 
the lobule was small and terminated abruptly at the antitragus. 
The intellect was normal. 

Sometimes an abnormal development of the superior crus 
of the anthelix pushes the helix upward and forward, giving 
rise to what is called the pointed ear. 

Anomalies of the Lobule. — The lobule is abnormally large 
in the black race, reaching such a development among the 
Kaffirs that by piercing it in a particular manner a sufficiently 
capacious cavity is formed within the lobule to serve as a 
pouch for carrying tobacco. 

Occasional!} the lobule is wanting, as in a case reported 



* Archiv fur Ohrenheilkunde, vol. xix, p. 55. 

+ Ibid., vol. xxi, p. 92. 

X Ibid., vol. xxii, pp. 51, 52. 



ANOMALIES OF THE TRAGUS, ETC. 



175 



by Binder, * while Szenes f mentions an instance in which the 
lobule was rudimentary ; there was also an absence of the ex- 
ternal auditory meatus and a faulty development of the 
corresponding side of the face. Probably the most frequent 




FlG. 65. — Anomalous division of the antihelix into three crura, the lower of which 
joins the crista helicis. (From a photograph.) 

deformity in this region is cleft lobule, the appearance re- 
sembling closely that seen when the lobule has been torn in 
the direction of its long axis, by the forcible removal of an ear- 
ring from the ear. 

Anomalies of the Tragus. — The tragus may extend back- 
ward and be of such size as to offer an actual obstruction to 
the entrance of sound waves into the meatus. McBride^: has 
observed a case in which there was a rudimentary tragus as- 
sociated with other abnormities of development. 

Anomalies of the Antitragus. — Malformation here is exceed- 
ingly rare. Szenes* observed an instance in which two spurs 
of cartilage projected from the antitragus into the canal. 



*Arch. tiir Psychiatrie, 1SS7, vol. xx, p. 2. 
f Arch, fur Ohrenheilkunde, vol. xxiv, p. 1S5. 
% Edinburgh Med. Journal, April, 1881. 
# Arch. fur Ohrenheilkunde, vol. xxvi, p. 140. 



176 CONGENITAL MALFORMATIONS OF THE AURICLE. 

II. An anomalous shape or a malposition of the entire 
auricle. 

This condition in its most pronounced form is commonly 
known as microtia, and depends upon an arrest or gerversion 
of the process of development which results in so complete a 
malformation that the distinctive parts of the external ear are 
no longer well defined. The condition may be unilateral or 
bilateral, and is frequently associated with co-existent malfor- 
mation of the deeper parts of the auditory apparatus. For 
this reason the condition merits special attention. Microtia is 
associated in the majority of instances with a complete ab- 




Fig. 66. — Microtia. 



sence of the external auditory meatus, or, in cases where the 
canal exists, it is a rudimentary structure ; the ossicular chain 
is frequently poorly developed or absent, and an anomalous 
condition is common in the labyrinth as well. 

The deformity may not be confined to the ear alone, but 
the entire side of the face may be poorly developed. The ap- 
pearances vary greatly in different cases, and an attempt to 
describe them would be but a recital of particular instances. 
Fig. 66 is a drawing of a case observed by the author. In 
this case the left ear presented an anomalous formation of the 



MICROTIA— MALPOSITION— TREATMENT. i yj 

antihelix (see Fig-. 65), while there was well-marked microtia 
upon the right side. At birth the right ear was much more 
deformed than the picture shows it to be, the helix at that 
time being adherent by its antero-superior border to the in- 
tegument in front. The cutaneous surfaces separated sponta- 
neously a few weeks after birth. 

Treatment. — Where the deformity is but moderate an at- 
tempt at correction by a plastic operation may be made in 
early childhood. Regarding any attempt to form an artifi- 
cial meatus, the results have been so unsatisfactory that it is 
seldom desirable to operate for this purpose. If the rudi- 
mentary canal is present, its size may be increased by surgical 
measures, but the frequent malformation of the deeper struc- 
tures commonly renders the operation futile in improving the 
function of the organ. If any attempt is to be made to restore 
the patency of the canal, it should be delayed until the patient 
is old enough to give information in regard to the power of 
sound perception either through the air or through the cra- 
nial bones. The technique of the operation for re-establishing 
the meatus will be described under polyotia. The plastic 
operation on the auricle for the relief of the deformity, how- 
ever, may be done very early. When a high degree of de- 
formity is present, it seems advisable to excise the entire au- 
ricle and supply its place by an artificial device rather than 
attempt its restoration by surgical measures, which will at 
the best leave a misshapen organ. 

From a practical point of view, one of the most interesting 
conditions included in this group is that in which the angle 
between the organ and the lateral aspect of the skull is con- 
siderable. This constitutes a deformity amenable to treat- 
ment, and, especially in the female sex, one for which we are 
occasionally consulted. If noticed in infancy, or even in early 
childhood, the simplest plan for correction is to coat the pos- 
terior aspect of the auricle and the adjacent cutaneous surface 
of the head with collodion, the ear being then pressed to the 
side of the head and held in position until it adheres. If nec- 
essary, several light strips of gauze may be passed over the 
top of the auricle, holding it closely to the side of the head, 
and fastened with collodion. Persistence in this plan of treat- 
ment will usually be successful in correcting the condition. 
In adult life little can be gained by this method, and resort 
must be had to some operative measure. This is best effected 



i;8 CONGENITAL MALFORMATIONS OF THE AURICLE. 

by removing an elliptical segment of the integument from the 
posterior surface of the auricle, the posterior incision passing 
just beyond the line of attachment to the auricle; the integu- 
ment is then dissected up from the posterior surface of the 
auricle for a sufficient distance to permit of an approxima- 
tion of the edges of the wound. Occasionally it is necessary 
to excise a segment of the cartilaginous framework as well, 
in order that the ear may be restored to the proper position. 
Usually the difficulty is sufficiently well overcome by approxi- 
mating the edges of the cutaneous wound without removing 
any of the cartilaginous framework, the tension due to the 
elasticity of the cartilage being easily overcome by the su- 
tures. Under aseptic precautions and with care, a perfect po- 
sition can be secured. General anaesthesia is usually neces- 
sary, although it is possible to perform the operation under 
local anaesthesia. It is well to operate upon the two organs 
separately, using the first as a standard to which the other is 
made to conform. 

III. The presense of some anomalous anatomical condi- 
tion, such as supernumerary appendages, fistulae, etc., in the 
region of the ear, the auricle being present either in its nor- 
mal form or being more or less misshapen. 

Auricular Appendages, the General Form of the Ear being 
preserved. — Abnormities belonging to this class are the sim- 
plest with which we have to deal. The most frequent region 
for the appearance of supernumerary appendages is the re- 
gion of the tragus. A case of this sort occurring in my own 
practice is shown in Fig. 6j. The prominent cartilaginous 
process constituting the deformity was located just above 
the right tragus, was about three fourths of an inch in length. 
and projected forward and outward. The tragus itself could 
be felt, but was rudimentary. 

Earth* cites an instance in which a rudimentary mam- 
mary gland was located just below the lobule upon one 
side. 

A condition belonging to this class constitutes what is 
known as ,4 fistula congenita auris " (Fig. 68). Its occurrence 
is due to an arrest in development of the auricle itself, or, as 
is believed by some, it indicates an incomplete closure of the 
first visceral cleft during fcetal life. That this is considered a 

* Yirchow's Archiv, vol. xii, part iii, 



AURICULAR APPENDAGES— FISTULA. 



179 



somewhat rare malformation is probably due to the fact that 
it seldom gives rise to symptoms, and consequently many 
cases pass unnoticed. Four cases of this deformity came 
under my own observation during- a period of about a year. 
Fig. 68 represents an appearance which is fairly typical. The 
deformity may occur either upon one side alone, or it may be 
bilateral. In one of my cases the fistula was located just above 
the tragus, while in another the orifice of the tract was situ- 
ated one inch above this point and presented an opening 
about one sixth of an inch in diameter through which a probe 
could be passed downward and inward for half an inch. On 





Fig. 67. — Auricular appendage. 



Fig. 68. 



-Fistula congenita auris. 
(a, fistula.) 



the opposite side the site of the fistula was occupied by a shal- 
low depression which did not admit even the finest probe. 
Occasionally a slight discharge exudes from the orifice of the 
fistula, and in a case reported by Pfliiger* the appearance of 
a purulent discharge from such a source was always preceded 
by acute pain in the ear. Where the wails of the sinus se- 
crete, a blocking of the orifice may cause a retention cvst of 
considerable dimensions. An instance of this is cited bv Ur- 
bantschitsch.f The most common location for such fistula 
is in the vicinity of the tragus, although they are occasionally 



* Monatsschrift fiir Ohrenheilkunde, 1874, No. it, 
f Lehrbuch der Ohrenheilk., third edition, 1S90, p. 94. 



8o CONGENITAL MALFORMATIONS OF THE AURICLE. 



met with in the helix and in other localities. Burnett * states 
that these fistulas may lead into the tympanic cavity. 

Treatment. — The appendages should be removed by 
means of the knife. The operation is exceedingly simple. 
When they present in the region of the tragus it is well in 
excising the growth to form a tegumentary flap from the cov- 
ering of the anterior surface of the appendage, which can be 
folded backward over the stump, bringing the line of the su- 
ture close to the entrance of the meatus, as the cicatrix is less 
visible in this position. 

Fistula congenita auris demands no treatment excepting 
in those instances where a retention cyst has been formed by 
the occlusion of the orifice of the sinus. This condition is re- 
lieved by a simple incision and the evacuation of the contents 
of the tumor, the walls being curetted with a sharp spoon to 
secure an obliteration of the cavity. 

Polyotia. — This term is applied to a congenital deformity 
in which, in addition to microtia, certain supernumerary 

growths are met with in 
the immediate vicinity of 
the ear, but entirely distinct 
from the deformed auricle. 
Occasionally they occur 
with a perfectly normal au- 
ricle, the fact that they are 
not attached to it distin- 
guishing them from the au- 
ricular appendages already 
described. The condition 
is sometimes associated with 
congenital aural fistula, as 
in the case reported by 
Burkner.f The deformity 
may be bilateral or unilat- 
eral, and the supplementary 
organ may present a variety of shapes, the most common 
being that of a small wartlike excrescence situated upon the 
cheek in front of the external meatus. When this multiple 
deformity exists there is usually considerable variation in 




Fig. 69.— Polyotia. 



* A Treatise on the Ear, Philadelphia, 1884, p 211. 
f Archiv fur Ohrenheilkunde, vol. xxn, p. 200. 



POLYOTI A— TREATMENT. 1 8 1 

size and shape between the members of the group. As 
already stated, a normal auricle is seldom found, although 
this may be the case. The condition usually occurs in con- 
nection with microtia. An instance of this kind, observed by 
me, is depicted in Fig. 69. The auricle upon the affected side 
was represented by a cutaneous fold, beneath which there was 
a cartilaginous framework. This was bent forward upon the 
cheek, covering the normal site of the meatus. Upon the pos- 
terior surface there was a well-defined groove between the 
cartilaginous and noncartilaginous portion. About three 
fourths of an inch in front of the anterior margin of this de- 
formed auricle was a small, wartlike prominence representing 
a second and rudimentary pinna, it being situated too far ante- 
riorly to represent the tragus. The fibro-cartilaginous lamella 
already mentioned was freely movable, and just beneath its 
attachment a slight depression could be felt. It was impossi- 
ble to determine whether the external auditory meatus was 
present or not. The ear of the opposite side was normal. 

The remarks made under microtia, regarding a faulty 
development or a complete absence of the deeper portions of 
the auditory apparatus apply equally well to the condition 
of polyotia. 

Treatment. — The small supernumerary appendages are 
usually easily removed, where they are large enough to con- 
stitute a serious deformity. The disfigurement which they 
cause is usually slight, however. For a correction of the 
larger malformed mass remaining, a plastic operation may be 
attempted, although, as in microtia, more satisfactory results 
may be expected by a complete removal of the deformed 
member, its place being supplied by an artificial substitute. 
Concerning the establishment of the meatus surgically, the 
remarks already made under microtia apply equally well 
here. Even if it is possible to construct the meatus, it is 
scarcely possible to secure a condition of permanent patency. 
When it seems desirable to attempt this operation the tech- 
nique is as follows : 

The field of operation being rendered thoroughly aseptic 
by shaving the parts and cleansing them with soap and water, 
and subsequently with ether, an incision is made just behind 
the attachment of the deformed pinna. The soft parts are 
divided, exposing the bone, after which the anterior flap, in- 
cluding the periosteum, is turned forward upon the cheek, ex- 



182 CONGENITAL MALFORMATIONS OF THE AURICLE. 

posing the region normally occupied by the external auditory 
canal. A thorough search must next be made for any open- 
ing in the bone which may represent a'rudimentary meatus, 
and if such a channel is discovered it should be cautiously en- 
larged, by means of either chisels or burs, the latter being 
propelled by an ordinary dental engine or an electric motor. 
When no fistula is present the bone may be cautiously exca- 
vated in the region corresponding to the proper position of 
the meatus. Great care is necessary during the entire pro- 
cedure, as damage may be done to important adjacent struc- 
tures. After the canal has been formed our means for secur- 
ing its patency will consist in the insertion of an aluminium or 
rubber tube, which will separate the opposite raw surfaces and 
allow the deep parts to be thoroughly cleansed, during cica- 
trization. As the anterior flap when replaced would cover- 
the newly formed channel, it should be perforated over the 
orifice of the meatus by making two incisions bisecting each 
other at right angles. Four triangular flaps are thus formed, 
wmich are to be inverted into the orifice of the canal and 
maintained in position for the first few days by a gauze pack- 
ing, alter which the metal or rubber tube already mentioned 
is to be employed. As soon as healthy granulations spring 
up, a method which suggests itself as exceedingly feasible 
would be Thiersch's method of skin grafting, as we might 
thus hope to secure a tegumentary lining to the passage and 
prevent its contraction during cicatrization. Such an opera- 
tion should only be performed at the earnest solicitation of the 
parents, in the case of a child, or, if the patient has reached 
adult life, only after the extreme uncertainty of the result has 
been fully explained. 



CHAPTER VI. 

WOUNDS AND INJURIES OF THE AURICLE. 

It is seldom that we see incised or punctured wounds in 
this particular portion of the body, although occasionally we 
are called upon to treat deformity which has resulted from 
wounds of this character inflicted at some preceding period. 
Here the ordinary rules of plastic surgery will enable us to 
secure satisfactory results. In performing any plastic opera- 
tion upon the auricle it is well to remember that when the 
entire thickness of the external ear is involved all sutures 
should be inserted upon the posterior surface of the organ, 
accurate approximation of the cutaneous edges being secured 
by passing the stitches deeply into the cartilaginous frame- 
work, but not bringing them out through the integument 
covering the anterior surface. 

In the treatment of lacerated wounds, which are more 
frequently met with, we should attempt to save as much tis- 
sue as possible, erring rather in this direction than in that 
of removing any part which possibly may possess sufficient 
vitality to survive. The edges of the wound should be 
thoroughly cleansed, and as a primary procedure a few sutures 
may be applied, holding the parts as nearly as possible in 
their normal position. It is a simple matter after the circula- 
tion has been thoroughly re-established to secure a more exact 
approximation and relieve whatever deformity ma} T be present. 
As the auricle is composed so largely of cartilage, any severe 
bruising of the tissue is likely to be followed by a sharp peri- 
chondritis, and unless there is so much laceration as to contra- 
indicate the plan, it is well to anticipate such an attack bv the 
employment of cold locally for the first twenty-four hours 
after the injury has been received ; subsequently proper atten- 
tion may be given to the correction of deformity. 

Contused wounds of the auricle without laceration of the 
integument are of frequent occurrence. Such an injury re- 

(183) 



1 84 WOUNDS AND INJURIES OF THE AURICLE. 

suits either in the formation of a hsematoma — an effusion of 
blood beneath the perichondrium — or in an acute perichon- 
dritis ; in either case the appearance is almost identical. The 
injured region is occupied by a somewhat spherical tumefac- 
tion, the normal outline entirely disappearing. Upon palpa- 
tion we discover that the contents of the tumor are evidently 
fluid. The surface varies considerably in color, according 
to the particular manner in which the injury was inflicted, 
and, to a less extent, the character of the fluid contained. If 
this is blood, the surface is of a dull deep-red color, while if 
the tumefaction is an evidence of a perichondritis, with an 
effusion of serum, the surface is of a much lighter tint, being 
either of a bright-rose tinge, or occasionally not differing 
widely from the integument covering the unaffected portion 
of the member. Either condition may remain quiescent for a 
long period ; may disappear spontaneously, leaving but slight, 
or marked deformity ; or, as a third possible termination, the 
contents may suppurate and be evacuated spontaneously. 

Where the contents consist of extravasated blood the car- 
tilaginous framework has usually been fractured, and certain 
portions will almost inevitably become necrotic and exfoliate 
with the production of considerable deformity. On the other 
hand, a simple perichondritis, where no fracture has taken 
place, may disappear without seriously changing the contour 
of the ear. 

Among professional wrestlers and boxers, the ear is fre- 
quently subjected to violence not sufficient to produce an 
acute perichondritis, but enough to cause a mild inflammation 
of the perichondrium, so slight as to give rise neither to dis- 
comfort to the patient nor to appreciable deformity immedi- 
ately after the injury. This chronic inflammation finally gives 
to the ear an appearance which is somewhat characteristic, 
known as " prize-fighter's ear," all the delicate outlines of the 
anterior surface of the pinna being obliterated by the deposit 
of new tissue in various localities. Occasionally the deformitv 
reaches such a high degree as to resemble closely the condi- 
tion resulting from a severe acute perichondritis with cartilagi- 
uous necrosis. 

Treatment. — The treatment of an acute perichondritis re- 
sulting from contusion consists, first, in the local application 
of cold, provided the case is seen within twenty-four hours after 
the injury has been inflicted. During this period the effusion 




TREATMENT OF CONTUSED WOUNDS. 185 

of serum will scarcely reach any considerable amount, and 
our efforts should be directed to the purpose of preventing 
the extravasation of fluid. The most convenient way of ap- 
plying cold is by means of the ice bag, 
shown in Fig. 70. The mastoid region 
should be covered by a pad of cotton 
so as to support the bag against the 
posterior surface of the auricle, while 
the anterior surface may be covered by 
a small flat ice bag. 

When seen at a later period and after 
effusion has taken place efforts should 
be directed toward the relief of the de- 
formity. It is a simple matter to as- 
pirate the effused fluid, and cause the FlG 7a _^ al ice bag . 
auricle to resume a perfectly normal ap- 
pearance, but unfortunately the result is often but temporary, 
effusion taking place again very soon. It is scarcely neces- 
sary to say that in aspirating the fluid, strict antiseptic pre- 
cautions as to the instruments and the field of operation 
should be observed. After the operation, it is well to insure 
close contact of the surfaces which have been separated by 
the effusion, by means of a clamp, the simplest device being 
an ordinary wooden spring clothes-pin, the spring being so 
weakened as to avoid undue pressure upon the auricle, while 
the skin is protected by covering the anterior and posterior 
aspect of the auricle with a thin pad of cotton. Such a device 
may be worn during the night, and may prevent, to a certain 
extent, the reappearance of the effusion. The pressure excites 
a slight inflammation, which may cause adhesion of the sep- 
arated surfaces and effectually prevent a reaccumulation of 
fluid. Unfortunately, aspiration is not attended by uniformly 
favorable results, and after it has failed once it is not advis- 
able to repeat the procedure. 

The most radical and satisfactory plan is to evacuate the 
fluid by a free incision so as to expose at the same time the 
interior of the sac sufficiently to permit of the proper treat- 
ment of its walls. When the fluid has escaped it is well to 
curette the walls of the sac by means of a sharp spoon, after 
which the cavity is packed with iodoform gauze, the aim be- 
ing to obliterate the space by granulation. In opening the 
cyst, care should be taken to make the line of incision conform 



1 86 WOUNDS AND INJURIES OF THE AURICLE. 

with one of the natural folds of the auricle, thus avoiding any 
deformity from the cicatrix. With proper care in conducting 
the operation, so as to avoid suppuration, recovery without 
appreciable deformity is the rule. 

When the case is seen at a still later period, and where the 
injury has been so severe as to result in cartilaginous necrosis, 
the only procedure available is that of incision. This should 
be free enough to permit of the removal of all disintegrated 
cartilage, softened areas being scraped with a sharp spoon 
until completely healthy tissue is reached. The subsequent 
treatment is the same as that advocated above. 

We have spoken of the various wounds which may occur 
in this region, and we need mention only those injuries which 
may be inflicted either by the potential cautery, by chemical 
agents, or by intense cold. Aside from the destruction of tis- 
sue which may result from the action of the potential cautery, 
or strong acids or alkalies upon the auricle, the effects pro- 
duced resemble closely those observed after severe contusions, 
the condition being essentially one of perichondritis. The 
wounds caused by the various escharotic agents, either poten- 
tial or chemical, will be treated upon general surgical princi- 
ples. The most common example of traumatism comprised 
under this head is that which follows exposure to intense cold. 
When the ears have been " frozen," if the patient presents im- 
mediately, the parts should be restored to their normal tem- 
perature gradually, by the application first of pounded ice and 
then of cold water, the temperature being increased gradually 
to avoid a sudden disturbance of circulation in the part af- 
fected. The ultimate result of a prolonged exposure to cold, 
may be a perichondritis followed by cartilaginous necrosis and 
the formation of sinuses upon the anterior and posterior sur- 
faces of the part. Such a condition is to be dealt with surgi- 
cally ; the sinuses must be laid open, all necrotic tissue re- 
moved, and the wound be allowed to heal by granulation. If 
care is taken but little deformity need result. 



CHAPTER VII. 

CUTANEOUS DISEASES OF THE AURICLE. 

Intertrigo. — This disease is observed most frequently in 
young children, in whom it is caused by the pernicious habit, 
so common among the laity, of covering the ears and pressing 
them close to the side of the head by means of a tight fitting 
cap or bonnet. Among the poorer classes this head-dress is 
worn for a great portion of the twenty-four hours. This habit 
is persisted in both in summer and winter, the result being that 
the cutaneous surfaces of the posterior aspect of the auricle 
and of the adjacent integument of the head are kept closely 
in contact, and under the influence of the natural heat and 
moisture of the body. The result is a desquamation of the 
superficial epithelium of the integument, leaving the deeper 
layer of the skin exposed to the air. When this has occurred 
over a small area the local process becomes intensified from 
the hypersecretion which takes place from the denuded sur- 
faces, and from the mechanical irritation produced by the child 
in its efforts to relieve the intense itching. When seen by the 
physician the adjacent surfaces of the auricle and of the side 
of the head are reddened and moistened with serum, which 
has transuded freely. There is no thickening of the integu- 
ment over the affected area, a fact which serves to distinguish 
the disease from eczema, which soon follows unless relief is 
obtained. 

Aside from the mechanical causes tending to produce the 
disease, it is probable that the condition is more commonly 
found among poorly nourished children than among those 
who are well cared for. An hereditary predisposition can 
scarcely be said to cause intertrigo, although it is more com- 
mon where there is a history of eczema in preceding genera- 
tions than where such history is wanting, the cutaneous struc- 
tures apparently, being more easily influenced bv a slight local 
exciting cause, as mechanical irritation, than would otherwise 

(187) 



188 CUTANEOUS DISEASES OF THE AURICLE. 

be the case. Lack of proper attention to cleanliness is nat- 
urally an important factor as well. 

The treatment consists merely in keeping the denuded sur- 
faces apart and protecting them from traumatism. All head 
gear which would keep these surfaces in contact should be 
discarded, and the affected areas should be separated by a thin 
layer of gauze smeared with vaseline, cold cream, or other 
bland oleaginous medicament. In mild cases merely dusting 
the surfaces with lycopodium powder, finely divided zinc ox- 
ide, zinc oleate, subnitrate of bismuth, or one of the various 
toilet powders in common use, will ordinarily be sufficient to 
correct the trouble. These applications relieve the itching, 
and consequently the child does not interfere with the prog- 
ress of the disease toward spontaneous recovery. 

Eczema. — This disease occurs either as an acute or chronic 
affection. In all cases probably, there is either some heredi- 
tary predisposition, such as a gouty or rheumatic diathesis, or 
some disordered condition of the primas vise, irregular habits 
of life, improper or insufficient food, etc. 

In addition to a predisposing cause some local exciting in- 
fluence can usually be made out. The most frequent among 
these is a discharge from the external auditory meatus. This 
condition, while in the vast majority of cases not leading to an 
eczema of the auricle, causes the disease in those predisposed 
to it on account of the reasons named above. Among chil- 
dren the habit of covering the ears, which results, as already 
mentioned, in an intertrigo, is frequently responsible for the 
appearance of eczema. 

At the beginning of an acute attack there is usually a feel- 
ing of burning or discomfort in some portion of the auricle, 
usually in those regions where the cutaneous surfaces are 
somewhat closely opposed, as in the fossa of the helix, or in 
the fissure intertragica, or at the orifice of the meatus, or just 
behind and below the lobule. In children the region imme- 
diately behind the ear is a favorite location. The feeling 
of discomfort soon changes to one of intense pruritus. To 
relieve this the patient scratches the part vigorously, in- 
creasing rather than diminishing the local hyperassthesia. 
The affected surface becomes reddened, soon loses its super- 
ficial epithelial layer, is moist from the transudation of se- 
rum, or in the later stages may be covered with crusts, the 
removal of which reveals the bright-red color of the inflamed 



ECZEMA— TREATMENT. 189 

integument. Instead of appearing in this form, we occasion- 
ally have a group of vesicles marking the affected locality. 
These vesicles, by inoculation from the air, soon become pus- 
tular, rupture, and give rise to thick, dirty yellowish crusts, 
the removal of which is frequently attended by slight haemor- 
rhage. The condition constitutes a true inflammation of the 
skin, with infiltration of its deeper layers. Palpation reveals 
this fact, the integument feeling thick and somewhat stiff over 
the entire affected area, this sensation diminishing gradually 
as the healthy integument is approached. Where a local cause 
is the most prominent factor the affection is unilateral, but 
where a strong constitutional element is present both organs 
are affected as a rule. When the disease begins upon the auri- 
cle the affection frequently spreads to the canal, producing 
symptoms which will be described later. Frequently after 
the disease has persisted for some time the superficial cervical 
lymphatics are enlarged. 

In the chronic form of the disease the entire auricle may 
be involved, or only limited portions of it. The part affected 
is either of a dull pinkish color, the surface being glossy and 
polished, as though the skin were very thin and tightly drawn, 
or in other cases the superficial epithelium is cast off too rap- 
idly, covering the surface here and there with minute whitish 
crusts or scales. From the efforts of the patient to relieve the 
pruritus these scales are picked off, frequently causing a slight 
abrasion of the surface, and increasing the activity of the local 
process. On palpation the skin feels hard, leathery, and thick, 
especially where the patient has subjected it to mechanical irri- 
tation for the relief of the itching. Over the unbroken surface 
the thickened integument has a peculiar smooth, glossy feel. 
De Rossi* has described a case in which the entire cartilagi- 
nous framework of the auricle became necrotic as the result 
of chronic eczema. It seems probable that there must have 
been some underlying cause other than eczema, to produce 
this destruction of tissue. 

Treatment. — Our treatment should be directed to the re- 
moval of the local exciting cause and to the relief of the con- 
stitutional element of which the disease is but a local manifes- 
tation. Thus in the acute form the dietarv of the patient will 
frequently need correction, and the elimination of certain arti- 

* Archiv fur Ohrenheilkunde, vol. xxi, p. 193. 
14 



190 CUTANEOUS DISEASES OF THE AURICLE. 

cles of food or the addition of others will be followed by sat- 
isfactory response to local applications. Diathetic conditions 
must be managed according to general rules. Moderately 
large doses of alkalies, either in the form of Rochelle salts, 
bi-carbonate, acetate, or citrate of sodium, frequently bring 
about a favorable termination where local treatment alone 
has been useless. 

Turning to the local measures to be employed, any dis- 
charge from the meatus must receive proper attention, as its 
presence excites the cutaneous infiltration. In the acute form 
our first efforts are to relieve the subjective symptoms. To 
this end cold applications in the form of evaporating lotions 
are of service. The ordinary lead and opium wash is a favor- 
ite remedy in the acute stage, but is disagreeable on account 
of the color which it imparts to the skin, and because of its 
characteristic odor. Such objections do not apply to the fol- 
lowing : 

9 Liquor plumbi subacetat 3 j ; 

Bismuthi subnitrat 3 ss. ; 

Morphinse gr. ij ; 

Glycerini § j ; 

Aquas rosae q. s. ad § viij. 

M. Sig. : Apply locally as a wet dressing. Shake before 
using. 

Instead of cold applications, better results are sometimes 
obtained, especially where the thickening is inconsiderable and 
the discharge from the surface profuse, by employing the local 
remedy in the form of a powder rather than as a solution. 
Here we may use the oxide of zinc, subnitrate of bismuth, 
starch, lycopodium, stearate of zinc, etc. Where the affection 
causes a most intense burning of the skin an oleaginous sub- 
stance is the most desirable vehicle. The following ointment 
may be used : 

^ Bismuth subnitratis 3 ij ; 

Acidi borici 3 j ; 

Morphinse gr. j ; 

Unguenti zinci oxidi § ss. ; 

Petrolati q. s. ad § j. 

The same emollient effect is obtained by employing the 
stearate of zinc in combination with boracic acid and sub- 
nitrate of bismuth, and the oily vehicle is avoided. 



ECZEMA— TREATMENT. 



I 9 I 



Owing to the frequency with which any condition attended 
with an increased secretion leads to the development of an 
aspergillus within the external auditory meatus, it is advisa- 
ble if the disease continues for any considerable period and in- 
volves the parts about the orifice of the canal, to add salicylic 
acid to any oleaginous preparation which may be employed 
as a local application, for the purpose of preventing the devel- 
opment of such a parasite. In order to act in this manner the 
salicylic acid must be present in the ointment in the propor- 
tion of about one and a half to two and a half per cent, a de- 
gree of concentration which does not act as an irritant to the 
sensitive cutis. Eitelberg * has employed an ointment of cre- 
olin in the strength of about two per cent with success. 
Where crust formation is a prominent feature of the affection, 
as occurs when the acute stage has passed, all aqueous solu- 
tions are contraindicated. The crusts should first be removed 
by softening them with olive oil or vaseline, after which the 
surface may be medicated either with one of the above oint- 
ments or with a proper powder. Salicylic acid in alcohol in 
the strength of twenty to forty grains to the ounce may 
occasionally be employed, although in my own experience 
alcohol has proved of but little service in eczema of the 
auricle. 

It should be remembered that the exposure of the denuded 
surface to the air is undesirable, and that the affected parts 
should be constantly protected by some non-irritant or slightly 
astringent ointment, such as the oxide of zinc, cold cream, or 
simple vaseline. 

Nitrate of silver in aqueous solution has many advocates 
as a remedy for the disease. It is customary in using this 
remedy, to begin the treatment with a solution of about ten 
grains to the ounce, the strength being increased until the de- 
sired effect is obtained. I have seen excellent results follow 
the application of such a solution, after the thickening has been 
reduced, as the stimulating effect of the astringent lotion has- 
tens the development of a protecting epithelial layer. 

Where the thickening of the integument is marked, a con- 
dition which must exist when the disease has persisted for any 
length of time, it will be impossible to effect a permanent cure 
without relieving the affected area of the serous infiltration. 

* Wien. med. Press., 1888, No. 13. 



192 



CUTANEOUS DISEASES OF THE AURICLE. 



It mav be possible, without doing this, to cause a temporary 
improvement, and to succeed in causing the part to become 
covered with a thin layer of superficial epithelium ; as soon as 
the treatment is discontinued, however, the disease will recur 
in an aggravated form, and where there is much induration we 
should direct our attention to this at once. For this purpose 
the area involved may be thoroughly scoured with green soap, 
the alkali which this contains causing a temporary stimulation 
of the surface, through which the tissues are relieved of the 
serous infiltration, by the free exudation of fluid. This process 
mav be repeated every second or third day until the integu- 
ment regains its normal texture, after which the use of emol- 
lient and astringent applications will cause a speedy return to 
a normal condition, and effect a permanent cure. A similar 
result may sometimes be obtained by an ointment containing 
chrvsarobin, or pyrogallic acid, or oil of cade. The ammoni- 
ated mercurial ointment also serves a similar purpose. My best 
results in this class of cases have been obtained by employing 
the acetum cantharidis, which quickly relieves the engorge- 
ment of the deeper layers of the integument, while at the same 
time the intense pruritus is alleviated. Considerable care is 
to be exercised in applying this remedy, since if it is used in 
too large quantities the surface may be blistered and the pa- 
tient be subjected to considerable discomfort. The acetum 
cantharidis is to be applied to the affected areas by means of 
a cotton mop, the parts being first lightly brushed with the 
solution and the application repeated on the following day if 
no effect has been produced. As a result of the application 
of this remedy a free serous transudation takes place, and soon 
the parts become covered with a normal epithelium, the ex- 
uded serum drying upon the surface in the form of a thin yel- 
lowish crust, which can either be removed with the aid of the 
forceps on the second day, or, if left to itself, will become dis- 
integrated and exfoliate as a thin, scaly desquamation. If the 
action of the cantharides is too vigorous the application of 
some oleaginous preparation for twenty-four hours will re- 
lieve all discomfort. The application of the cantharides may 
be repeated at frequent intervals until the infiltration has en- 
tirely disappeared. 

We should add, in closing, that constitutional medication 
and local applications must go hand in hand in combating 
the affection under consideration. 



PEMPHIGUS— HERPES. 



193 



Pemphigus. — This is a somewhat rare cutaneous disease, 
but is occasionally observed. Its characteristic appearance 
differs in no way from pemphigus developing- upon other 
portions of the body. The condition manifests itself in the 
formation of large blebs filled with a clear serous fluid. Al- 
though the favorite site for the development upon the auricle 
is the margin of the helix and the lobule, it is occasionally 
found in other situations. 

From local infection, this serous fluid may become turbid, 
but it is rarely purulent. The bullae rupture spontaneously 
at the end of a few days, and if the walls are not destroyed, 
protect the denuded area which they cover, and are subse- 
quently cast off in the form of scales, their former site being 
marked by a slight redness of the integument. On the other 
hand, if the sac is entirely destroyed an eroded surface is 
left. This seldom persists for any length of time, becoming 
rapidly dry, the integument remaining slightly reddened in 
this situation. No pain attends these local manifestations, and 
the disease is of importance simply on account of the fact that 
the patient is ordinarily afflicted by several successive crops 
of bullae, which are a source of annoyance because of the dis- 
figurement. 

The best results are obtained by puncturing the thin en- 
velope which incloses the fluid, and coating the collapsed sac 
with a layer of flexible collodion to protect the surface be- 
neath. The internal use of arsenic is the best prophylactic 
measure against recurrence. 

Herpes. — This condition is extremely rare, although a 
search through otological literature furnishes us with quite a 
number of instances of the affection. The disease is essen- 
tially the same as herpes zoster, differing from it only in the 
locality of the cutaneous manifestation. Neurotic subjects 
are particularly predisposed to the affection, although it oc- 
casionally attacks those in perfect health. Indiscretions in 
diet, faulty assimilation, and improper and insufficient food 
may be mentioned among the other predisposing causes. As 
an exciting cause, exposure to cold is the most important ; 
while in a case reported by Chatellier,* it was caused bv local 
irritation. The particular pathological condition is obscure. 
but probably consists in a neuritis of the trophic nerves which 

* Annales des mal. de l'oreille., 1S86, No. 6. 



194 



CUTANEOUS DISEASES OF THE AURICLE. 



supply the parts involved. These are the auricularis magnus 
and the auriculotemporal, the former coming from the cervi- 
cal plexus, the latter from the third branch of the trigeminus. 

The onset of the affection is commonly marked by severe 
constitutional disturbance, such as an acceleration of the pulse, 
an elevation of the temperature, varying in degree from ioo° 
to 102° Fahr., or even 103 Fahr., headache, and a feeling of 
general lassitude. The characteristic subjective evidence is 
the intense neuralgic pain, which may be confined to the ear 
or may spread over the entire side of the face, following the 
general area of distribution of the nerves involved. Since the 
pain may precede the eruption by several days, the exact diag- 
nosis is often difficult. When the eruption appears, we find 
the portion of the auricle involved covered with groups of 
vesicles which rise from a reddish base and are filled with 
clear serum. Occasionally they coalesce and form a bullous 
eruption. The anterior surface of the auricle is generally 
the region attacked, although in a case reported by Green * 
the posterior surface was involved. The manifestation is 
ordinarilv unilateral, but Wagenhaiiser f observed an instance 
in which it was bilateral. Although usually confined to the 
auricle, the affection may spread to the canal. A few days 
after their appearance the vesicles rupture, their envelope 
becomes dry and is cast off in the form of minute scales, leav- 
ing the integument beneath of a somewhat reddened or brown- 
ish hue. 

In cachectic individuals superficial ulceration may persist 
for a considerable time over the site of the vesicles. The 
constitutional symptoms, which have been so marked before 
the vesicles appear, usually abate when the eruption becomes 
well marked, although this is not an invariable rule, and the 
general symptoms may persist for a long period after the local 
lesion has entirely disappeared. 

Since diathetic conditions are a prominent causative factor, 
the patient seldom escapes with a single attack of the dis- 
ease, a second or third recurrence being the rule. 

Treatment. — Measures directed toward the relief of the 
condition divide themselves into those for the control of the 
constitutional symptoms and those for the relief of the local 

* American Journal of Otology, vol. iii, Xo 2. 
f Arch, fur Ohrenheilkunde, vol. xxvii, p. 159. 



HERPES, TREATMENT— SYPHILIS. 



195 



manifestations. Our first measure should be a thorough cleans- 
ing of the alimentary canal by a brisk saline purge, the dietary 
of the patient being at the same time restricted so as to em- 
brace only the simplest articles of food. When the febrile 
movement is prominent the ordinary antipyretics, such as 
antifebrin, antipyrin, or phenacetin, should be administered, 
the last-named drug exerting a favorable influence upon the 
neuralgic pain. When the pain is of unusual severity, aconitia 
in doses of one five hundredth of a grain, repeated every 
hour for three or four doses until the constitutional effects of 
the drug are felt, after which the interval should be increased 
to every three or four hours, can be relied upon to give re- 
lief. Before the appearance of the eruption, cold applications 
are grateful. Iced cloths, the aural ice bag, or a cold lead- 
and-opium lotion may be employed for this purpose. The 
vesicles are best treated by dusting them with a bland powder 
to prevent their early rupture, and where they are confluent 
they ma}'- be coated with collodion, for the same purpose. 

If the vesicles are infected and the serous fluid becomes 
purulent, their contents should be evacuated by means of 
a small knife, and the exposed area be dusted with iodo- 
form, iodol, dermatol, or touched lightly with a solution of 
nitrate of silver, to hasten the reparative process. An emolli- 
ent ointment containing morphine or opium is occasionally of 
value. It has been suggested, as a rational means of con- 
trolling the disease, that counter-irritation, by means of the 
actual cautery or by vesicants, be employed over the trunk 
of the nerve involved, but little success has attended this 
method of treatment. Regarding the subcutaneous injection 
of morphine over the affected nerve, it should be remembered 
that disfigurement occasionally follows the use of the hypo- 
dermic needle, and it seems that the advantages are not suf- 
ficient to warrant the physician urging this plan of treat- 
ment. 

Syphilis. — Any syphilitic lesion may appear upon the pin- 
na, although a cutaneous manifestation of this constitutional 
disease is of rare occurrence in the region under consideration. 
Zucker* has reported an instance in which the initial lesion 
was situated upon the tragus, the part being of a dark-pur- 
plish color, and swollen to twice the natural size. There was 

*Zeit. fur Ohrenheilkunde, vol. xiii, p. 167. 



196 cutaneous diseases of the auricle. 

concomitant enlargement of the submaxillary and parotid 
glands. 

The erythematous syphiloderm undoubtedly attacks the 
auricle but, since it causes no symptoms to call attention to 
its presence, is usually overlooked. The macular eruption 
is more frequently observed on account of the distinctive 
appearance to which it gives rise. Occasionally it spreads 
into the canal, for a considerable distance. According to 
Taylor,* those parts supported by cartilage are more fre- 
quently attacked. The papular syphilide is of interest chiefly 
on account of the superficial ulcerations to which it occa- 
sionally gives rise. In an instance under my own obser- 
vation such an ulceration had developed at the junction 
of the lobule with the integument, just below the mastoid. 
The erosion was sharply defined, the surface only slightly 
depressed, and but a slight areola was present. The appear- 
ance resembled an intertrigo so closely that an exact diag- 
nosis was made only upon the failure of the erosion to clear 
up under ordinary local treatment, and its prompt disappear- 
ance upon specific medication. 

A specific eruption of a tubercular character is occasion- 
ally observed. The ulcerated areas are covered by large 
crusts, upon the removal of which the outline of the affected 
portion is seen to be sharply defined. Either the anterior or 
the posterior surface of the external ear may be attacked. A 
correct diagnosis is possible by bearing in mind the sharply 
defined outline of the specific ulceration, its reddish color in 
contradistinction from the irregular grayish-white color of 
tubercular or lupoid ulceration, its slightly depressed surface, 
which is comparatively smooth, in contradistinction to the 
nodular appearance observed in the affections just named, and 
the history of an antecedent specific infection. 

The appearance of a gummy tumor in the external ear is 
one of the rarest manifestations of the constitutional poison. 
Baratoux f has reported an instance in which the infiltration 
was multiple. The deposit presents as a hard, smooth tumor, 
of a deep-red color, and in the early stages does not fluctuate 
upon palpation. At a later period the centre of the mass be- 
comes necrotic, the disintegrated tissue finally breaking down 



* Cited by Rupp, Journal of Cutaneous and Genito- Urinary Diseases, Oct., il 
f Cited by Rupp, loc. cit. 



SYPHILIS, TREATMENT— LUPUS ERYTHEMATOSUS. 197 

to form pus, which is evacuated spontaneously, unless pre- 
vented by the institution of surgical measures. When left to 
itself the local necrosis results in the development of a deep 
ulcer. 

Treatment. — The treatment of specific lesions of the auri- 
cle corresponds to that of similar conditions in other portions 
of the body. If a gummatous deposit is found before disin- 
tegration has begun, an effort should be made to cause its 
absorption, although this at first may seem hopeless. 

Where ulceration has taken place before the patient comes 
under observation, large doses of the iodide of potassium 
should be at once administered, and for a time local treat- 
ment should consist simply in keeping the parts clean, since 
the reparative process which this drug institutes, frequently 
preserves tissues which seem so disintegrated that the surgeon 
would have no hope of saving them. After the internal med- 
ication has been persisted in for a short time, and its antag- 
onistic action on the constitutional infection is observed in 
the ulceration, we should no longer hesitate to remove all 
those portions which are manifestly beyond repair. The sharp 
spoon is to be called into requisition, and all softened tissue 
thoroughly scraped away. The dressing is carried out upon 
general surgical principles. 

Lupus Erythematosus. — This affection usually attacks the 
auricle secondarily, some other portion of the face being the 
starting point. At first it presents as a sharply defined red- 
dened area, slightly elevated above the surface of the skin, 
over which it soon spreads in all directions. The integument 
involved becomes thick, injected, and separated from the nor- 
mal cutis by a rather sharp line of demarcation. The surface 
is frequently traversed by minute veins. Owing to the in- 
terference with the blood supply, the superficial epithelium is 
thrown off more rapidly than under normal conditions, giving 
the surface a glazed appearance. As the disease encroaches 
more and more upon the healthy integument, its starting 
point becomes somewhat depressed and of a lighter color, 
owing to the gradual sclerosis of the infiltrated tissue. The 
disfigurement constitutes the entire inconvenience which the 
affection entails, there being no pain, pruritus, or perversion 
of sensation. Although usually unilateral, I remember one 
instance in which the entire face, including both auricles, was 
involved. 



1 98 CUTANEOUS DISEASES OF THE AURICLE. 

A mistake in diagnosis is practically impossible, although 
to a certain extent the disease resembles eczema. In the lat- 
ter affection the intense pruritus, the presence of some local 
exciting cause, the brighter color of the affected part, and 
the moist surface, together with the more rapid progress, 
will usually render a differential diagnosis easy. 

Treatment. — Locally we may employ vigorous friction 
with a strong alkaline soap to relieve the infiltration, after 
which an astringent or soothing ointment may be applied. 
Another plan is to employ counter-irritation in the form of 
tincture of iodine. An ointment containing either iodine and 
iodide of potassium or pyrogallic acid in the strength of from 
one to four per cent is also valuable. 

In the severe cases, the galvano-cautery, the curette, or 
even the knife may be employed, although as a rule these 
vigorous measures are not followed by satisfactory results. 

Lupus Vulgaris. — Dermatological literature teaches us 
that this is one of the rarer cutaneous affections, and its loca- 
tion in the external ear is still more unusual. In the early 
stages we find upon some portion of the auricle one or more 
small hard nodules which cause a slight sensation of itching ; 
the efforts of the patient to relieve this abrade the surface of 
the elevation, which soon becomes covered with a brownish 
crust. As the disease advances the infiltrated areas increase 
in size and number. Those which appear subsequently un- 
dergo the same changes already described as characteristic 
of the original deposit. 

The progress of the affection is slow but steady. The ero- 
sion of the surface gradually becomes deeper and constitutes 
a true ulceration, the areas of local necrosis being almost im- 
mediately covered by brownish crusts which do not separate 
spontaneously. When the crusts are removed artificially the 
ulcer appears but slightly depressed, its margins are poorly 
defined, there is no areola, its boundaries merging impercep- 
tibly into the normal integument. Still later there seems to 
be an effort at spontaneous cicatrization, which results in con- 
siderable deformity due to a shrinking of the cicatrix. The 
affection does not cease spontaneously, and will almost surely 
involve the entire auricle unless checked by local measures. 

Treatment. — When first seen, it is our duty to remove the 
involved area as completely as possible, provided the disease 
is in its earliest stage and limited in extent. In many cases 



LUPUS VULGARIS— TREATMENT. 



199 



the complete excision of the infiltrated portion of the auricle 
is the simplest and best measure. Another method is to thor- 
oughly curette away the deposit with a sharp spoon, care 
being taken that the healthy tissue immediately surrounding 
the deposit is encroached upon. The curettement should be 
followed by the application of some chemical agent, lactic acid 
being probably the best. This should be used in concentrated 
solution, and should be thoroughly rubbed into the tissues. 
From the fact that the canal, and even the middle ear, may be 
attacked if the progress in the auricle is not checked, the 
surgeon is fully justified in excising the entire auricle if this 
is so infiltrated as to permit of no other means of eradicating 
the disease. 



CHAPTER VIII. 



INFLAMMATORY AFFECTIONS OF THE AURICLE. 



Perichondritis. — We have already described an inflamma- 
tory condition of the cartilaginous framework of the external 
ear following an injury to the part. Occasionally such a con- 
dition is met with as an idiopathic affection, or is a complica- 
tion of an acute inflammation of the external auditory meatus. 
The particular part of the auricle affected will depend largely 
upon the locality occupied by the inflammatory process in the 

external auditory meatus, the dis- 
ease spreading by contiguity of 
structure, when depending upon 
such a cause. 

The symptoms to which the 
disease gives rise are a feeling of 
heat in the external ear, quickly 
followed by severe pain. The 
auricle soon begins to increase 
in size, while over the affected 
area the skin is of a bright-red 
hue, due to an increased arterial 
vascularity. As the disease ad- 
vances the part becomes more 
and more swollen, and the nor- 
mal outline of the auricle entire- 
ly disappears. This is due to an 
effusion of fluid between the car- 
tilage and perichondrium, dis- 
secting this last named structure 
from the underlying cartilage. The fluid is at first serous, 
but quickly becomes purulent. The deformity varies con- 
siderably, according to the particular area involved. Where 
the inflammatory condition within the meatus involves the 
anterior wall, the tragus alone is the part usually affected, 

(200) 




Fig. 71. — Deformity following peri 
chondritis. 



PERICHONDRITIS— ERYSIPELAS— ABSCESS. 2 OI 

while if the circumscribed inflammatory process is situated 
upon the posterior or superior walls of the canal, the peri- 
chondritis is apt to be extensive, and is accompanied by 
marked deformity. If unrelieved by therapeutic measures 
the fluid is evacuated spontaneously. In such an event 
several sinuses appear either upon the anterior or posterior 
surface of the pinna, and close spontaneously only after a 
prolonged period. A high degree of deformity is the usual 
result in those cases which are allowed to progress without 
surgical interference (Fig. 71). 

Treatment. — The treatment of the condition is identical 
with that advocated in considering perichondritis due to 
traumatic causes, with the exception that aspiration of the 
fluid is not admissible, since its purulent character precludes 
the possibility of a favorable result. In the severe cases 
the procedure advocated by Gruening * of " through-and- 
through " drainage is probably the most advisable plan 
of treatment. This consists in thoroughly opening the ab- 
scess by means of incisions which pass completely through 
the substance of the auricle from the anterior to the pos- 
terior surface, strips of iodoform gauze being subsequently 
passed through the openings thus made. In a case under the 
care of the author the tragus was the part involved, and a 
rapid cure followed free incision, with a thorough curetting 
of the cavity. 

Erysipelas. — This affection occurs as a complication of 
facial erysipelas, and requires no special consideration either 
as regards the clinical course which it runs, or the treatment 
to be instituted for its relief. 

Abscess. — An abscess of the auricle involving its cartilagi- 
nous portion constitutes in reality a perichondritis, a con- 
dition which has already been described in detail. Occasion- 
ally we meet with a localized collection of pus in that portion 
of the auricle consisting of fibrous and fatty tissue — the lobule. 
Most frequently the affection depends upon a local infection, 
either from an earring or following the operation of piercing 
the ears. Evacuation of the abscess by incision is followed 
by complete and rapid recovery. 

Occasionally we find a superficial abscess in other portions 
of the auricle, the cartilaginous framework being uninvolved ; 

* Archives of Otology, vol. xix, p. 22. 



202 INFLAMMATORY AFFECTIONS OF THE AURICLE. 



these constitute really retention cysts, and are caused bv the 
blocking up of the orifice of a sebaceous follicle with sub- 
sequent disintegration of the retained secretion. In the early 
stages, when the condition is one of retention only, remoyal 
of the obstruction is all that is necessary. After decomposi- 
tion has taken place, however, the proper procedure is to in- 
cise the tumor freely, after which the lining membrane is to 
be dissected out or thoroughly curetted, to prevent recur- 
rence. 

Othematoma (Fig. 72). — A transudation of sanguineous 
fluid beneath the perichondrium is frequently met with as the 
result of an injury. Occurring, however, without the history 

of traumatism, the origin of the 
condition has been a matter of no 
little speculation. While haema- 
toma auris is frequently met with 
among the insane, numerous au- 
thentic reports are found in which 
the affection has occurred sponta- 
neously, in persons of perfectly 
sound mind. Age seems to exert 
but little causative influence, Weil * 
having reported a case occurring 
at the age of fifteen months. 

The condition is present usu- 
ally upon one side only, although 
in a case reported by Brunner f 
its occurrence upon one side was 
followed, a year later, by a similar 
condition in the opposite organ. 
From the fact that it has been frequently observed among 
the insane it is possible that some intracranial lesion may be 
responsible for its occurrence. The investigations of Brown- 
Sequard J would add weight to this view, since they show 
that section of the restiform bodies in dogs will produce the 
local lesion in question. It is quite probable that in many 
cases an injury which has been entirely forgotten is the real 
cause of the pathological condition. Flesch # believes that 




Fig. 72. — Othematoma. 



* Monatsschrift fur Ohrenheilkunde, 1SS3, No. 3. 
f Archiv fur Ohrenheilkunde, vol. v, 26. 

% Canstatter Jahresbericht, 1869, vol. ii, p. 27. 

* Archiv fur Ohrenheilkunde, vol. xx, p. 291. 



OTHEMATOMA— TREATMENT. 203 

certain variations in the structure of the auricular cartilages 
predispose to the extravasation of blood, but advances no 
theory as to the cause of the anomalous structure of the car- 
tilage. It can only be said, therefore, that the setiological 
factor in a proportion of the cases is still unsolved. 

The affection consists essentially in an effusion of blood, 
which separates the perichondrium from the cartilage. Oc- 
casionally we find, on examining the walls of the cavity, that 
small plates of cartilage have been forcibly torn from the 
framework of the auricle during the process of extravasation. 
The tumefaction appears, as a rule, somewhat suddenly. It 
may be preceded by a feeling of burning or pruritus, but usu- 
ally there are no prodromal symptoms. The anterior surface 
of the auricle is usually involved to a greater or less extent, 
and the obliteration of the normal outline is correspondingly 
complete. The integument covering the tumor is either 
normal in color or, if the effusion is large in amount, may ap- 
pear pale on account of the pressure. 

After its appearance, the effusion may disappear spon- 
taneously, or it may be evacuated by spontaneous rupture, 
or the contents of the cyst may suppurate. Absorption is so 
uncommon that we should never wait for its occurrence, 
while it is probable that traumatism is responsible for the 
spontaneous evacuation of the fluid in most cases, whether 
this occurs with or without suppuration. 

Treatment. — The treatment varies according to the size 
of the tumor and nature of its contents, whether this consists 
of blood alone or whether purulent infection has already oc- 
curred. 

When there are evidences of pus formation free evacua- 
tion should be at once resorted to, the case being treated as 
one of simple perichondritis. 

Where the tumor is small and of recent occurrence, simple 
pressure by means of a compress held firmly in place by a 
roller bandage should first be tried. This method, combined 
with systematic massage of the auricle, is valuable in many 
instances. In tumors of large size resort may be had to 
aspiration, followed by the compress, bandage, and massage. 
Where the effusion is of such proportions as to cause consid- 
erable tension of the overlying tissues, evacuation by free 
incision is the most advisable procedure, the cavity being 
afterward thoroughly curetted to remove all necrotic tissue 



204 INFLAMMATORY AFFECTIONS OF THE AURICLE. 

and to favor a rapid obliteration of the space by granulation 
and adhesion. After thus thoroughly removing the contents 
of the cyst the wound should be packed firmly with iodoform 
gauze, and subsequently managed according to the rules of 
general surgery. 

It should always be remembered that in the severe cases 
considerable deformity of the auricle mav follow, and the 
patient should be warned accordingly. 

Thickening of the Lobule. — This condition consists of a 
hvpertrophv both of the connective tissue forming the frame- 
work of the lobule and of the glandular structures of the re- 
gion, as the result of a chronic inflammatory process. The 
most frequent cause of the affection is mechanical irritation, 
occasioned by the wearing of a ring in the ear, the margins 
of the artificial opening through which this is passed instead 
of cicatrizing and becoming covered with normal epithelium 
remaining: denuded, and thus afford an avenue for the entrance 
of infectious germs. Some metals are easily acted upon bv 
moist air. and are particularly prone to cause such a condi- 
tion, the products of their oxidation destroying the newlv 
formed epithelial cells and leading to the result above given. 
When this process has continued for some length of time the 
pendent portion of the auricle becomes elongated, thickened. 
tender to the touch, and in some cases the seat of spontaneous 
pain. The chief annoyance to which it gives rise, however, 
is the deformitv. Occasionallv the lodgment of more virulent 
bacteria upon this denuded surface produces small abscesses. 

Treatment. — The treatment of the condition is simple, 
and consists first in the removal of the local cause. If the 
deformity has reached a high degree a plastic operation mav 
become necessarv for the removal of the superabundant tissue. 

Ossification. — Curiously enough, this condition is exceed- 
inglv rare, although several instances have been mentioned in 
otological literature. The causes which may be considered 
to be active in its production seem to be malnutrition, severe 
local inflammation, or some profound disturbance of the cir- 
culation of the part, such as exposure to intense cold. When 
osseous tissue has once been deposited, the recognition of 
the affection is exceedingly simple. The auricle becomes 
stiff, inflexible, and boardlike to the touch. The ossification 
mav be limited either to a small area or mav involve a con- 
siderable portion of the organ. 



OSSIFICATION— GANGRENE. 



205 



In a case reported by Linsmayer * the bony deposit ex- 
tended into the floor of the canal. The helix, scaphoid fossa, 
and antihelix are the regions most frequently affected, and the 
condition may be present upon one or both sides. Relief is 
demanded both on account of the deformity and also because 
of the pain which any pressure upon the rigid organ causes, 
as when the patient attempts to lie upon the affected side. 

Treatment. — The treatment consists in a removal of the 
abnormal deposit where this is of limited extent. Where a 
large part of the auricle is involved amputation of the entire 
organ is justifiable. 

Gangrene. — Complete necrosis of the tissues making up 
the framework and coverings of the external ear is occasion- 
ally met with in cases which have not been subjected to any 
severe traumatism. A marked general cachectic condition, 
following an acute illness which has lowered the vitality of 
the patient greatly, or such as may be occasioned by some 
prolonged suppurative process accompanied by bony necro- 
sis, frequently acts as a predisposing cause. If we combine 
with such a condition slight but continuous pressure upon 
the auricle, as might occur in a patient confined to bed for a 
long period and lying upon one side for a considerable inter- 
val of time, the pressure might be sufficient to determine the 
process under consideration. 

Treatment. — The treatment is sufficiently indicated by 
the causes operative in producing the affection. Supporting 
and stimulating measures are to be adopted for the removal 
of the predisposing cause, while care is to be taken to prevent 
any pressure upon the auricle, bearing in mind the ease with 
which local nutritive processes are interfered with when the 
general tone of the body is greatly lowered. If the process 
has already developed we should attempt, by means of warm 
applications, to restore the circulation of the region to its 
normal state, and at the same time to favor spontaneous 
separation of the necrotic tissue if local necrosis has occurred. 
Where the necrosis is but superficial, the application of 
strong chemical caustics may hasten repair, the local irrita- 
tion exciting a reactive inflammation which in itself becomes 
a valuable therapeutic measure, causing the early exfoliation 
of the slough and the development of healthy granulations. 



* Wien. Klin. Woch., 18S9, No. 12. 
15 



CHAPTER IX. 

BENIGN TUMORS OF THE AURICLE. 

Fibroma. — A fibroid tumor is one of the most common of 
the benign neoplasms which is met with upon the auricle. 
The lobule is the part usually involved. The negro race 
is especially liable to the affection, and among this people 
the growths frequently attain a large size. Local irritation 





FlG. 73. — Soft fibroma filling Fig. 73a. — Fibroma of lobule. 

the concha. (Anton.) (Author's case.) 

attendant upon wearing ornaments in the ear is the most 
common exciting serological factor. Although the lobule 
is the part most frequently affected, the concha is occasion- 
ally the site of a growth of this character, and in a case 
reported by Habermann * the external meatus was partially 
occluded by the tumor, which sprang from the concha. 

Upon physical examination the tumor presents a hard 
surface, which is usually smooth, but occasionally nodular. 
Microscopically the mass is made up of dense, white, fibrous 
connective tissue. In a case reported by Anton f (Fig. 73) 
the growth was a soft fibroma and contained many con- 
nective-tissue cells interspersed between the fibres. 

* Archiv fur Ohrenheilkunde, vol. xviii, p. 76. 
f Ibid., vol. xxviii, p. 285. 
(206) 



FIBROMA— LIPOMA— ATHEROMA. 207 

These growths are of especial interest on account of the 
fact that they frequently recur after removal, the recurrent 
tumors occasionally assuming a malignant type, especially 
after repeated operations of excision have been instituted. 

Treatment. — The operative treatment is simple. The mass 
is to be circumscribed with the knife, the incision extending 
through the entire thickness of the affected part and lying 
completely outside of it, within healthy tissue. After the neo- 
plasm has been extirpated the edges of the wound are to be 
brought together by sutures, and the parts dressed according 
to general surgical rules. Recovery is usually uninterrupted. 

Where the tumor involves the lobule the incision should 
be so located as to effect the removal of redundant tissue and 
enable the parts, upon replacement, to be molded into a form 
symmetrical with that of the lobule of the opposite side. 

In addition to pure fibromata, tumors are occasionally met 
with which are made up of a mixture of fibrous tissue with 
myxomatous, cartilaginous, or other elements. In a case re- 
ported by Haug * the growth was lymphangio-fibroma. 

Lipoma. — A true fatty tumor has, so far as I know, never 
been found upon the auricle itself. They are occasionally met 
with, however, in its immediate vicinity, usually just below 
the lobule. Kipp f has reported a case of fibro-lipoma of the 
concha, the microscope showing the presence of cavernous 
tissue as well. 

Atheroma (Figs. 74 and 75). — A tumor of this character 
results from blocking up of the sebaceous follicles with which 
the integument covering the external ear is supplied. The 
secretion which the glands produce is imprisoned by the ste- 
nosis of the orifices of the ducts, dilates the gland cavity, and 
gives rise to a tumefaction of varying size. Where the gland 
is active, the rapid formation of its product may produce so 
much pressure as to cause spontaneous rupture. On the 
other hand, after attaining a certain size the obstruction in 
the duct may be overcome, allowing a sufficient amount of 
the contents to escape to relieve the tension without restor- 
ing the normal patency of the tube. This process may be 
repeated indefinitely, and the patient presents with the his- 
tory of a recurrent discharge from the growth at varying 



* Archiv fiir Ohrenheilkunde, vol. xxxii, p. 161. 

f Transactions of the American Otological Society, vol. iii. part iii. 



208 



BENIGN TUMORS OF THE AURICLE. 




intervals. Again, the pressure may be so severe as to excite 
an inflammation within the sac, with the consequent produc- 
tion of a purulent discharge. 

The lobule is a favorite seat for these 
growths, or the junction of the lobule with 
the skin of the neck. Marian- has re- 
ported a case in which the neoplasm filled 
the concha. Where spontaneous evacua- 
tion has not taken place dissection usually 
reveals a distinct sac. Where the con- 
tents of the cyst have undergone infection 
and rupture has occurred as the result of 
an inflammatory process, the lining mem- 
brane is usually so amalgamated with the 
surrounding tissues 
as to render its rec- 
ognition as a dis- 
tinct structure dif- 
ficult. 

Under the mi- 
croscope the con- 
tents of such a tu- 
mor is found to be made up of seba- 
ceous material, degenerated epithelial 
cells, with an occasional admixture of 
cholesterin crystals. 

Treatment. — This condition is best 
combated by surgical interference. 
This consists in the removal of the 
growth. An incision is made through 
the overlying integument, and the tu- 
mor is shelled out from the envelope 
without rupture of the sac. In this way a possible recur- 
rence is guarded against. Such a procedure, however, is 
frequently impossible, the sac being opened and its contents 
being evacuated in spite of the greatest care. In this event 
the entire sac should be completely dissected out from the 
structures with which it has become amalgamated. It is well 
after making such a dissection to thoroughly curette the cav- 
ity by means of a sharp spoon, in order that every vestige 



Fig. 74. — Atheroma. 




Fig. 75. — Sebaceous tumor of 
the lobule. (Claiborne.) 



Archiv fur Ohrenheilkunde, vol. xxv, p. 66. 



ATHEROMA— TREATMENT— ANGIOMA. 209 

of the enveloping membrane may be removed. Where the 
mass is of but small dimensions and spontaneous discharge 
has taken place, a thorough curetting of the sac, followed by 
the application of a strong solution of nitrate of silver, may 
cause complete obliteration of the cavity and prevent a re- 
currence. 

Angioma. — A neoplasm of this character is seldom met 
with in the external ear, and the reported cases have varied 
greatly both in the area involved by the neoplasm and in the 
degree to which the vascular abnormity has developed. In 
a case reported by Chimani* the condition was one of cirsoid 
aneurism which was present upon the left side of the head at 
birth, and subsequently extended until a large portion of the 
auricle was involved, particularly the posterior aspect of the 
organ. The external ear was displaced outward, and was of 
a dark purplish-red color ; a distinct murmur was perceptible 
over the growth. The condition improved somewhat under 
injections of perchloride of iron, although recurrence took 
place at a subsequent period. The mass was completely dis- 
sipated by a repetition of the same treatment. 

Occasionally an exposure to cold, as in Kipp's f case, seems 
to be responsible for the affection, although in many instances 
they are congenital, differing only in degree from the com- 
mon birthmark or port-wine stain. 

Although we do not consider the condition as perilous to 
life, Jungken J has reported an instance in which haemorrhage 
from the growth terminated fatally. 

Treatment. — We are usually consulted on account of the 
deformity which these growths cause, and the measures for 
their relief must depend upon their size and character, and 
the coincident presence of a similar condition upon some 
other portion of the face. When involving only the integu- 
ment and consisting of a small stain, repeated applications of 
the galvano-cautery usually obliterate the abnormity. Where 
the mass is of large size and the vessels are more fully devel- 
oped, complete excision is the best procedure. This may be 
effected by seizing the base of the mass with a clamp and re- 
moving it in toto, ligating the stump in several portions. In 
other instances the clamp may be dispensed with, and the 

*Archiv fiir Ohrenheilkunde, vol. viii, p. 63. 

■f Transactions of the American Otological Society, Tulv, 1SS5. 

\ Schwartze, Ohrenheilkunde, p. 77. 



2io BENIGN TUMORS OF THE AURICLE. 

mass dissected out, the vessels being divided between two 
ligatures, thus preventing excessive haemorrhage during the 
operation. The emplovment of the ligature to cause the 
growth to slough away slowly is scarcely advisable. 

Injections of fluids for the purpose of coagulating the con- 
tents of the tumor are not free from danger, since by the dis- 
lodgment of a clot, embolism of important vessels may fol- 
low, or general sepsis may result. 

The emplovment of the galvano-cautery knife or loop for 
the excision of such a neoplasm should only be undertaken if 
a clamp is used, and even if the mass were removed in this 
manner most would prefer to ligate the pedicle in several por- 
tions rather than to trust to a closure of the vessels by the 
action of the incandescent blade or wire. 

Where the tumor increases rapidly in size at the site of its 
first appearance and other areas of the integument become 
involved in regions entirely distinct from the original location, 
we have to deal not only with the lesion as it appears upon 
the external ear. but by our measures for the relief of this, we 
should aim to prevent a similar condition from developing 
subsequently in neighboring regions. This can only be ef- 
fected. I think, by shutting off the arterial supply of the entire 
region by the ligation of the trunk from which the various 
vessels spring. After such an operation the dilated vessels 
will in manv instances be obliterated, while those remaining 1 
will be much diminished in size, and any remaining angioma- 
tous masses can be treated upon the rules already laid 
down. 

It should be remembered that the vessels upon one side of 
the face anastomose freely with those upon the opposite side. 
and less radical measures than those given above may not 
be sufficient to obliterate the condition. 

Cystoma 'Fig. 761. — It is still a matter of discussion as to 
what particular form of neoplasm this term should be applied. 
Many use it to designate a localized tumefaction upon the 
auricle due to a circumscribed collection of fluid not de- 
pendent upon traumatism. Many again apply to similar con- 
ditions the term haematoma or perichondritis, although there 
may be no evidence of a sanguineous effusion or of an inflam- 
matory process, and although the history may reveal no ade- 
quate cause for the occurrence of either affection. The for- 
mer view seems to me the more tenable and is advocated 






CYSTOMA. 



211 




by Hartmann,* who applies the name of cyst of the auricle to 
tumors of this description. This opinion is supported by the 
appearance of the interior of the sac, upon incision of the 
tumor. There is no evidence of 
any inflammation of the perichon- 
drium ; there are no fibrinous 
clots, nor any other evidence of a 
previous traumatism. The devel- 
opment seems to depend upon an 
effusion of serum simply. Exposed 
cartilage, however, is occasionally 
found within the cyst. 

These tumors make their ap- 
pearance, as a rule, upon the an- 
terior surface of the auricle, which 
they involve more or less com- 
pletely. The overlying integu- 
ment is normal in color and not 
tender to the touch. The tume- 
faction appears quite suddenly, 
and shows little or no tendency to 

increase in size, relief being demanded simply on account of 
the deformity. Harsh manipulation or contusion of the part 
may cause an inflammation of the cartilage, but this condition 
is superadded, and not a part of the original process. 

The cause of the affection is naturally hypothetical. It 
may possibly be due to a degeneration in the cartilaginous 
framework of the auricle, somewhat similar to that which 
causes the spontaneous development of a hasmatoma auris. 

Treatment. — The treatment consists in repeated aspira- 
tion of the fluid or of evacuation by incision, after which 
the cavity is obliterated by packing the wound with gauze. 
Fischenisch f has obtained good results by massage in these 
cases. Manipulation in conjunction with aspiration is cer- 
tainly worthy of trial. After evacuation of the contents of the 
cyst in this manner the walls should be kept in contact by 
means of a properly constructed clamp or bv a firm bandage. 

Certainly the surest method of treating these cases is by 
incision. This should be made in one of the natural folds so 



Fig. 76. — Cystoma of auricle. 



* Zeitschrift fiir Ohrenheilkunde, vol. xv, p. 156, and vol. xvii, p. 232, 
f Archiv fiir Ohrenheilkunde, vol. xxv, p. 299. 



212 BENIGN TUMORS OF THE AURICLE. 

as to prevent deformity. After the sac has been thoroughly 
cleansed by irrigation, the margins of the incision may be 
sutured, a few strands of horsehair being passed through the 
sac to act as a drain. Bv this method a sligfht irregularity 
may remain at the upper and lower extremities of the incision 
at the points of entrance and exit of the horsehair drain. To 
avoid this, the entire wound upon the anterior surface may 
be sutured, and drainage secured by puncturing the cartilage 
so as to make an opening upon the posterior surface of the 
auricle. Bv securing drainage through this channel, and 
allowing the incision upon the anterior surface to unite by 
first intention, the probability of recurrence is reduced and 
all deformity avoided. 

Papilloma. — Simple papillomata are found upon the auricle 
onlv in the form of warts. Two instances of anomalous devel- 
opments in the epidermal laver have been reported, which 
might properly be classed under this term. These were ob- 
served by Buck. * and consisted of a dense, hornlike pro- 
tuberance springing from the outer and posterior portion of 
the helix, in one of these the excrescence attained a length 
of three fourths of an inch, while the base was nearly as 
broad. Its growth had undoubtedly been favored by harsh 




Fig. 762. — Horny growth from lobule. 
(Author's case.) 

methods of treatment. The mass was removed, and complete 
recovery followed. 

* Manual of Diseases of the Ear. New York, iS5o. pp. =2. ". 



CHAPTER X. 

MALIGNANT TUMORS OF THE AURICLE AND OF THE MEATUS. 

It is comparatively seldom that the external ear is the 
primary seat of a malignant neoplasm, although the condition 
is occasionally met with. Any portion of the external ear 
may be the site of the primary deposit, from which situation 
the neoplasm may spread in any direction until a large area is 
involved. In some instances the growth originates in the ex- 
ternal auditory meatus, the auricle being attacked subsequent- 
ly, or the reverse may be true, the growth appearing first 
upon the pinna and extending into the auditory meatus. 

Malignant neoplasms of the deeper portions of the ear or 
mastoid process are still more infrequently met with. The 
most common malignant growth which affects the region in 
question is epithelioma, sarcoma being of rare occurrence. 

Epithelioma. — The same causes operative upon other por- 
tions of the body in the production of malignant growths, act 
here to produce the condition. In a number of instances per- 
sistent mechanical irritation has seemed to be the most prom- 
inent causative factor. In these cases a slight abrasion of the 
external ear subsequently becomes the seat of a malignant 
ulceration on account of the persistent efforts of the patient to 
relieve the local discomfort to which it gives rise. Individuals 
under the age of fifty are seldom attacked, although in one 
instance a malignant growth developed at the age of nineteen. 

The progress of these tumors is usually slower than in the 
other regions of the body, several years being required for 
them to reach any considerable size. Secondary enlargement 
of the cervical glands is not ordinarily present, and for this 
reason the prognosis in malignant disease of the auricle is 
relatively better than that of a similar condition in other 
portions of the body. Even where glandular infiltration has 
occurred there seems to have been little tendencv to sys- 
temic infection, and removal of the original mass and of the 
affected lymphatics has been, in the majority of cases, effec- 

(213) 



2i 4 MALIGNANT TUMORS OF THE AURICLE AND MEATUS. 

tual in curing the disease. That systemic infection is so 
slight in cancer of the external ear is probably due to the 
fact that the infectious material is absorbed from cartilaginous 
tissue very slowly, and that the local lesion develops to such 
an extent that it demands removal before extensive glandular 
infiltration has taken place. 

The physical characteristics are almost unmistakable. No 
ulceration resembles in appearance that presented by an epi- 
thelioma. Before ulceration has taken place it may be im- 
possible to decide the character of the neoplasm, although 
:r m the fact that it does not resemble any of the benign 
growths found here, diagnosis by exclusion is simple. 

After the superficial tissues have broken down the eroded 
surface appears reddened, moist, irregular in outline, and some- 
what raised above the healthy integument surrounding it. 
It bleeds easily on touch, and is frequently tender. Interfer- 
ence with the nutritive supply of the cartilage causes this 
to become necrotic, and with the process of exfoliation inflam- 
matorv reaction occurs. Such a condition is characterized 
bv the presence of exuberant granulations the same as in a 
simple perichondritis, and during this stage an error in diag- 
nosis may occasionally be made. The true character of the 
tumor can be made out by removing a small portion and sub- 
mitting it to a microscopical examination. The removal of a 
small fragment is easily accomplished by means of the cold 
wire snare, and this aid to diagnosis should always be em- 
ployed before a positive opinion is given. On account of the 
occurrence of exuberant granulation tissue, microscopical evi- 
dence of a negative character does not exclude malignant dis- 
ease, although positive evidence settles the question beyond 
a doubt. 

Treatment. — The results of treatment are unusually favor- 
able. If the mass is removed by radical measures there seems 
to be slight tendency to a recurrence. Lymphatic infiltration 
should be dealt with at the same time, and it is only in ad- 
vanced cases that a fairly favorable prognosis is unwarrant- 
able. The treatment should be the same as that of malignant 
neoplasms in any portion of the bodv. early removal by the 
knife being the only safe procedure. Care should be taken 
that every vestige of the growth is excised, the incision pass- 
ing beyond the limits of infiltration and lying in perfectly 
healthy tissue. The exact plan to follow will vary with the 



EPITHELIOMA— TREATMENT. 



215 



different cases. If the auricle alone is involved, and the in- 
filtration is extensive, it is best to amputate the pinna at once. 
If possible, when this is done care should be taken to pre- 
serve enough of the integument about the orifice of the 
meatus to permit of its being sutured to the skin of the face, 
thus securing a patulous external canal lined with epidermis. 
Where, however, the growth has extended ever so slightly 
into the canal, the auricle and the entire cartilaginous meatus 
should be removed. When this is necessary it is almost hope- 
less to attempt to secure a patent external meatus, although 
the effort should be made. For this purpose a drainage tube, 
either of soft rubber, silver, or aluminium, should be kept con- 
stantly in the canal in order to preserve its lumen. Such a 
device may be worn for a long period, and be removed once 
daily for the purpose of cleansing the passage, being quickly 
replaced to prevent the occlusion of the canal by the granu- 
lation tissue. Even after such a tube has been worn many 
months the attempt frequently fails. It may be possible in 
some instances to employ skin grafting, either by Thiersch's 
method or by twisting a small flap from the adjoining region 
into the orifice of the canal, and thus secure a proper tegumen- 
tary lining. I have tried neither of these methods, since the 
procedure was not suited to the two cases which came under 
my observation. In one instance, where the growth involved 
the posterior wall of the canal, the meatus was completely ob- 
literated in spite of persistent efforts to maintain its patency. 
In a second case a perfectly patent canal was obtained by 
uniting the integument of the anterior wall of the passage 
with the margin of the cutaneous incision through the skin of 
the face, the cutis being dissected up for a considerable dis- 
tance to permit displacement toward the meatus. Coaptation 
of the edges was not attained, and this does not seem to be 
necessary. The sutures may cut through at the end of a few 
hours and still perform a very important function, the parts 
being held in position for a sufficient length of time to become 
so firmly fixed by plastic effusion as not to retract to any ex- 
tent after the sutures have given way. In the instance named. 
a considerable portion of the wound healed by granulation, 
and there was scarcely any deformity, and but slight con- 
traction at the entrance of the meatus. 

In excising a growth of this character involving a large 
portion of the auricle, a little care will enable the operator to 



2i6 MALIGNANT TUMORS OF THE AURICLE AND MEATUS. 

replace the parts in such a manner as to prevent disfigure- 
ment. Where the parotid gland is involved, it is seldom wise 
to attempt extirpation, although in a robust patient it is per- 
missible. As the facial nerve passes through this large glan- 
dular mass, it is well to warn the patient of the possibility of 
facial paralysis following the operation. 

No special suggestions are necessary concerning the 
course to be pursued with the lymphatic enlargements. 
These are dealt with on general surgical principles. The 
employment of the galvano-cautery, the cold snare, chemical 
caustics, etc., for the removal or the destruction of a malig- 
nant neoplasm of the auricle seems to the author scarcely 
justifiable, although many have used the potential cautery 
upon small growths of this character, with eminently satis- 
factory results. 

Sarcoma. — Occasionally a sarcomatous neoplasm origi- 
nates primarily in the external ear, or, on the other hand, 
this organ may be involved by contiguity of structure from a 
similar growth in the cervical region. The growth exhibits 
no preference for any particular region, any part of the exter- 
nal ear being equally liable to involvement. Extension to the 
external auditory meatus has occurred, and the possibility of 
this should always be borne in mind. Such an extension to the 
canal renders extirpation of the growth less easy and the pos- 
sibility of its occurrence constitutes a plea for early operation. 

The tumor varies in appearance according to its situation, 
and differs from an epithelioma in that ulceration of the sur- 
face does not take place until a comparatively late period. 
The mass is less firm than an epitheliomatous tumor, is usu- 
ally more vascular, the surface being frequently traversed by 
tortuous blood vessels. The tumor may grow slowly and 
exist for many years without giving rise to symptoms suffi- 
ciently urgent to demand operative treatment ; on the other 
hand, these tumors sometimes increase rapidly in size and 
demand interference at an early period. 

Treatment. — The successful treatment depends upon the 
complete removal of the growth, and in these cases, owing to 
the increased vascularity of the mass, it may be wise to em- 
ploy the cold or incandescent ecraseur or the galvano-cautery 
knife. If the mass is completely removed at the point of pri- 
mary deposit, recurrence seldom occurs. Systemic infection 
is rare. 



II. DISEASES OF THE EXTERNAL AUDITORY 

ME A TUS. 

Diseases of the external auditory canal may be divided 
into two classes as regards their causation, duration, and 
extent. 

As regards causation, either primary or secondary. 

As regards duration, either acute or chronic. 

As regards extent, either circumscribed or diffuse. 

While inflammatory changes in this region are often sec- 
ondary to some coexisting condition of the tympanum, either 
circumscribed or diffuse inflammation may occur as an idio' 
pathic disease both in the acute and chronic form. 



CHAPTER XI. 

circumscribed external otitis. 

Acute Circumscribed External Otitis. 

Otitis externa circumscripta acuta. Fu?'uncle. 

Etiology. — The occurrence of a circumscribed inflamma- 
tion within the auditory canal is usually due either to mechan- 
ical irritation, the result of scratching the ear with the finger 
or with some blunt or sharp instrument; to inoculation in the 
same manner ; to a loss of superficial epithelium as a result 
of some cutaneous disease, the abraded surface formincr the 
point of entrance for pathological bacteria; or, where the tym- 
panum is the seat of a purulent inflammation, the local infec- 
tion may take place through the ducts of the glands with 
which the meatus is supplied. 

It is doubtful, probably, whether all cases are not the 
result of some local infection, but certain constitutional con- 
ditions predispose strongly to the disease under considera- 
tion. The local lesion sometimes appears without any dis- 

(217) 



2i8 CIRCUMSCRIBED EXTERNAL OTITIS. 

cernible source of local infection — in other words, it occurs 
as an idiopathic disease. Marked impairment of the general 
health, disturbance of the digestive system, anaemia, and dia- 
betes render an individual particularly susceptible to the 
malady. 

Pathology. — From the anatomical structure of the meatus, 
it follows that as the external or fibro-cartilaginous portion 
is freely supplied with glands, this is the part most usually 
attacked. The inferior, posterior, and superior walls are 
more frequently affected than is the anterior. Usually the 
focus of the inflammation is situated near the orifice of the 
meatus, although it may be located in any portion of the 
canal, and occasionally is met with in the osseous part. The 
abscesses occur usually in groups rather than singly, due to 
the fact, probably, that infectious material from the same 
source has inoculated several glands simultaneously. The 
disappearance of one " crop " is apt to be followed by an- 
other, thus prolonging the course of the affection. This is 
especially true where any diathetic condition is present. 

Loewenberg * lays great stress upon the fact that certain 
micro-organisms are found in the pus discharged from these 
small abscesses. Schimmelbusch,f working in the same line, 
likewise attributes the local abscess to the presence of a ba- 
cillus, but has shown that, an abrasion of the normal epithe- 
lium is necessary in order that the germ may develop at any 
point. It has already been stated that an asthenic constitu- 
tional condition in many cases predisposes to the formation 
of these abscesses, the power of resistance to any morbid pro- 
cess under these circumstances being much reduced. There 
is considerable evidence to show that a trophic disturbance 
caused by some obscure condition in the nerve trunks which 
supply the meatus may also be the prominent causative 
factor. 

Urbantschitsch J has reported instances where a derange- 
ment of the trophic nerves of one side, due to a local lesion, 
was followed very quickly by the development of a furuncle 
in that portion of the canal of the opposite side, supplied by 
the corresponding nerve. I myself have seen two cases 



* Deutsch. Med. Woch., 1888, No. 28. 

f Arch, fur Ohrenheilk., vol. xxvii, p. 252. 

% Lehrb. der Ohrenheilk., Vienna, 1890, p. 107 ; Arch, fur Ohren., vol. xxxv, p, 5. 



PATHOLOGY— SYMPTOMATOLOGY. 219 

which were undoubtedly of a reflex trophoneurotic character. 
One occurred in a boy, aged fifteen, who suffered from a 
severe traumatic external otitis, the abscess being located on 
the posterior wall of the canal. Notwithstanding the fact 
that the patient was in excellent general condition, the oppo- 
site canal, which was apparently healthy up to this time, was 
similarly affected about four days after the incision of the 
first abscess. The identity in the location of the abscess 
upon either side and the absence of any other exciting cause, 
seemed to place this second furuncle in the category under 
discussion. In the second case the development of a small, 
circumscribed area of inflammation upon the floor of the 
right meatus was followed within twenty-four hours by an 
exactly similar condition in the same location upon the oppo- 
site side. In this short interval the local process had reached 
maturity, and when the patient was seen the second abscess 
was discharging, although the region had been inspected with 
great care less than twenty-four hours previously, and was, 
at that time, in a perfectly normal condition. 

We must believe, therefore, that the cause may be reflex 
in character even in cases where the general health is unim- 
paired. After infection has taken place, the inflammatory pro- 
cess advances rapidly, the central portion of the affected area 
losing its vitality and being discharged either in the form of 
pus or sometimes as a distinct mass of necrotic tissue. Ordi- 
narily the inflammation does not extend deeply by contiguity 
of structure, but when very severe the underlying tissues 
may become affected, developing a perichondritis of the canal 
or auricle. This is particularly apt to take place when the 
furuncle is located on the anterior wall, the entire tragus be- 
coming involved. Exceptionally, the affection may lead to a 
diffuse external otitis, which, spreading along the posterior 
wall of the canal, may give rise to periosteitis of the osseous 
portion, and may thus by extension involve the middle ear 
itself. In either event extension to the mastoid cells may 
occur. 

Symptomatology. — The first symptoms with which the dis- 
ease is ushered in is usually a feeling of fullness or discomfort 
in the ear, or sometimes a slight itching sensation, causing the 
patient to press the finger against the tragus. Soon, how- 
ever, he finds that this part is tender upon pressure, and 
a little later spontaneous pain in the ear becomes very well 



220 CIRCUMSCRIBED EXTERNAL OTITIS. 

marked. At this juncture the hearing becomes considerably 
interfered with, owing to the stenosis of the meatus resulting 
from the tumefaction. For the same reason there is fre- 
quently tinnitus, usually rather high pitched in character, 
which increases as the affection progresses. This may be 
due either to stenosis of the canal or to the congestion of the 
deeper structures from the increased blood supply. The 
pain increases in severity, so that within twenty-four hours 
from the first feelings of discomfort it may be almost un- 
bearable, while the ear continues to be very tender to the 
touch, especially when pressure is exerted in front of the tra- 
gus. From the intimate relation between the cartilage of the 
tragus and the intermaxillary articulation the motions of the 
loAver jaw are interfered with, and mastication frequently be- 
comes so painful that the patient can take liquid food only. 
The spontaneous pain is especially severe at night and fre- 
quently may prevent sleep, although during the day the pa- 
tient may be able to follow his vocation. If the abscess is 
located upon the anterior wall of the canal the parts in front 
of the ear appear swollen and slightly turgescent. If, on the 
contrary, the posterior wall of the canal is affected, one of the 
frequent symptoms noticed is an undue prominence of the 
auricle, the external ear being crowded somewhat forward 
and standing out more prominently from the side of the head 
than does its fellow on the opposite side. When the furuncle 
is in this location, also, the slightest pressure upon any por- 
tion of the pinna causes intense suffering. When the abscess 
is situated upon the posterior wall, a not infrequent symptom, 
and one to which the patient is apt to attach undue gravity, 
is a marked oedema of the integument behind the ear. 

Infiltration of the cervical glands, and also of the preau- 
ricular glands, is of common occurrence, the former giving 
rise to a hard, irregular swelling extending from just below 
the lobule downward along the course of the sterno-mastoid 
muscle to the angle of the jaw, while in the latter case the 
side of the face immediately in front of the ear presents some 
irregular induration due to an inflammation of the lymphatic 
nodules in this region. The parotid gland itself may also par- 
ticipate in this inflammatory process, causing its outline to 
become distinctly defined both to ocular* inspection and to 
palpation. This is due to secondary engorgement of the 
gland, and consequently suppurative inflammation of the paro- 



DIAGNOSIS. 221 

tid occasionally complicates a circumscribed external otitis. 
Occasionally we find directly behind the auricle, a rather 
prominent group of small lymphatic glands ; when these are 
present a localized inflammation upon the posterior wall of 
the canal is attended by considerable infiltration of these 
structures, in which case the oedema before spoken of is re- 
placed by an irregular induration which is so poorly defined 
in its limitations, that it may be mistaken for an inflammatory 
condition of the mastoid periosteum. 

Constitutional symptoms are, as a rule, not well marked. 
The attack may run its course in an adult with scarcely any 
elevation of temperature, or the temperature may be slightly 
elevated — reaching perhaps 99 or ioo°. If glandular inflam- 
mation is present as a secondary affection, the temperature is 
more apt to be elevated than when this does not exist. A feel- 
ing of general malaise, headache, loss of appetite, etc., is attrib- 
utable rather to the loss of sleep and the discomfort attendant 
upon the condition within the canal than to any actual systemic 
infection. After these symptoms have persisted for from forty- 
eight hours to three or four days, they disappear quite sud- 
denly, and coincident with their cessation a purulent discharge 
appears in the meatus. This, it need scarcely be stated, is due 
to the spontaneous rupture of the abscess, the discharge of its 
contents causing an abatement of all the distressing manifes- 
tations. 

As stated under Pathology, however, these abscesses ordi- 
narily appear in groups, so that in the course of a few days 
the symptoms already narrated are repeated. If the inflam- 
matory process extends to the tympanum or to the mastoid 
cells, the pain becomes more intense and the constitutional 
symptoms also are more marked. The temperature rises, the 
pain instead of being localized involves the entire temporal 
region, or may manifest itself as a severe general headache. 
The impairment in hearing and the subjective disturbances 
become more marked, and the gravity of the affection is evi- 
denced by the increased prostration from which the patient 
suffers. 

Diagnosis. — It would seem that the diagnosis of such an 
affection would present no difficulties, but this is frequently 
by no means simple. In the early stages the patient is not 
able to localize the pain, but complains simply of a feeling 
discomfort and heaviness in the head, and may even ignore 
16 



222 



CIRCUMSCRIBED EXTERNAL OTITIS. 



the ear entirely and refer all the painful sensations to the pres- 
ence of carious teeth. An inspection of the ear at this period 
may reveal absolutely nothing. If, however, we supplement 
ocular inspection by carefully testing the sensitiveness of the 
walls of the canal by means of a cotton-tipped probe, usually 
some one point will be found where pressure causes the pa- 
tient to wince slightly. Too much stress can not be laid, how- 
ever, upon the necessity of first inspecting the ear without the 
use of the speculum, the auricle being drawn upward and 
backward, or in a very young child downward and backward, 
and the entrance of the meatus first examined by reflected 
light before the introduction of any instrument. It is well, 
also, to press gently upon the posterior, inferior, superior, and 
anterior walls of the canal with the cotton-tipped probe before 
introducing the speculum, in order to recognize any tender 
point which might escape detection after the insertion of the 
instrument. Very frequently, at an early stage, this tender- 
ness may be the only evidence suggestive of the local lesion. 
If this examination is made before the speculum is inserted, 
a very slight tumefaction may be observed encroaching upon 
the lumen of the canal, from one of its walls. This area may 
not differ in color from the surrounding parts, or it may be 

of a slightly pinkish or red- 
dish hue. This alteration 
in color is seldom notice- 
able, and the insertion of the 
speculum may entirely ob- 
literate the local swelling. 
The deeper parts should be 
tested, after the speculum 
has been introduced, by 
means of the probe in the 
manner already described, 
and the presence of one or 
more tender points be 
looked upon with suspicion. 
If the local process is more 
advanced the areas of tume- 
faction are easily recognized 
(Fig. yy) ; if the inflammatory process is located near the 
orifice of the canal, the introduction of the speculum may be 
painful. As many patients, however, wince slightly upon 




FlG. 77. — Otitis externa acuta circumscripta, 
at the entrance of the canal involving the 
superior and posterior walls. (Natural 
size.) 



DIAGNOSIS. 



223 



the introduction of any instrument into the meatus, this sign 
should be accepted with considerable caution. As has been 
stated, circumscribed inflammation of the canal is usually 
located in the movable portion, and although occasionally 
occurring in the osseous segment, any localized tumefaction 
in this region should be looked upon with great suspicion, 
especially if situated upon the superior posterior wall, since 
in this locality the mastoid antrum is separated from the 
meatus by a comparatively thin plate of bone, and an inflam- 
mation within the mastoid cells often causes an encroachment 
upon the lumen of the canal in this locality. When this is 
the condition otoscopic ex- 
amination gives the impres- 
sion of a canal which rapid- 
ly becomes narrow at the 
fundus, the line of demar- 
cation between the drum 
membrane and the superior 
and posterior walls of the 
meatus being poorly de- 
fined. In some instances 
only a small slitlike open- 
ing is visible at the inner 
extremity of the canal, the 
membrana tympani being 
completely hidden from 
view except over this area 
(Fig. 78). Such a condition 

means, almost invariably, a collection of fluid within the mas- 
toid antrum, and always indicates an affection of the deeper 
structures, although the process may have had its origin in 
the external meatus ; in other words, the affection is no longer 
confined to the meatus, but involves the middle ear. On the 
contrary, in furuncular inflammation the greatest narrowing 
is at the orifice of the meatus, and if the speculum can once 
be carried past this obstruction, which lies comparatively 
near the external opening of the canal, an unobstructed view 
can be obtained of the parts that lie beyond. Where a cir- 
cumscribed external otitis occurs in an ear which is already 
the seat of a purulent inflammation of the tympanum, the 
location of the tumefaction in the superficial meatus will fre- 
quently enable us to distinguish between a simple circum- 




Fig. 78. — Otitis externa acuta of the deep 
portion of the meatus, indicative of in- 
flammation of the mastoid. (Natural 
size.) 



224 



CIRCUMSCRIBED EXTERNAL OTITIS. 



scribed external otitis and one due to an inflammation of the 
mastoid process (compare Figs. 77 and 78). 

External manipulation will reveal considerable tenderness 
upon pressure in front of the tragus if the anterior wall is af- 
fected ; indeed, as the entire fibro-cartilaginous portion of the 
canal is moved, to a certain extent, by any pressure in this 
region, this test in adults is of great importance in making the 
differential diagnosis between inflammatory affections of the 
meatus as distinguished from those of deeper parts — that is, of 
the middle ear or of the mastoid process. In the same way 
if the auricle be grasped firmly and moved in various direc- 
tions, any inflammation in the canal will be evidenced by the 
pain which this manipulation causes. It is also well to exert 
pressure upon the walls of the canal from below upward and 
from above downward, and from behind forward successively. 
If the cartilaginous meatus is affected it will be scarcely pos- 
sible not to elicit some tenderness, no matter where the ab- 
scess is located. The occurrence of oedema over the mastoid 
process may lead to the erroneous supposition that the osseous 
structures have become involved. This mistake need never 
be made if care is taken to test for the presence of tenderness 
over the mastoid process itself, without communicating any 
motion to the auricle in applying the pressure. To do this 
the ringers of the hand are rested lightly upon the side of the 
head, while the thumb is pressed firmly over the cedematous 
area, taking care that this pressure shall be exerted just be- 
hind the line of insertion of the auricle, and in a direction 
backward and inward rather than forward and inward. In 
this way the movable portion of the canal is in no way dis- 
turbed and the pressure is brought to bear directly upon the 
mastoid process. It will be found that where the inflamma- 
tion is confined to the canal alone no tenderness is elicited by 
this manipulation, although the thumb may sink quite deeply 
into the cedematous tissues and leave its imprint there when 
removed. As soon, however, as the pressure is directed in 
the slightest degree forward, so as to move either the auricle 
or the fibro-cartilaginous canal, the patient gives evidence of 
intense suffering. Although simple in execution this point is 
of great value, especially in differential diagnosis. In the 
same manner a careful examination of the glandular infiltra- 
tion, either behind the ear Ox below it, will usually enable 
one to recognize its nature in distinction from a mastoid peri- 



PROGNOSIS. 



225 



osteitis, or an extravasation of pus due to the spontaneous 
evacuation of the mastoid abscess beneath the sterno-mastoid 
muscle through the diagastric fossa. In some instances, how- 
ever, it will be necessary to observe the condition for several 
days before an exact opinion can be arrived at. 

A suppurative inflammation of the parotid gland may oc- 
casionally lead to error. This condition, from the local ten- 
derness, the severe pain upon mastication, and the local tu- 
mefaction of the antero-inferior wall of the canal just within 
the orifice of the meatus, may sometimes be mistaken for a 
furuncle ; especially is this the case when we remember that 
we frequently find the parotid enlarged secondarily as the 
result of the circumscribed external otitis located here. Prac- 
tically such an error would be a matter of no significance, 
since the treatment would be the same. Upon evacuation of 
the abscess, either spontaneously or by incision, the quantity 
of pus discharged would readily show whether we had to 
deal with simple localized inflammation of the canal, or with 
a breaking down of the substance of the parotid, in which the 
pus had made its way to the surface in this situation. 

Prognosis. — When uncomplicated, the affection ordinarily 
runs its course in from four to eight days, the symptoms 
being at their height about the third day. Care must be exer- 
cised in expressing an opinion upon this point, as the succes- 
sive infection of other areas may prolong the affection consid- 
erably. The general health of the patient is a fact of great 
importance in considering how rapidly the termination of 
the disease may be expected, reinfection being much more 
apt to take place if the general condition is impaired. Per- 
sonal cleanliness, precise attention in carrying out the local 
measures instituted for the relief of the condition, and the 
avoidance of any unnecessary handling of the part — all aid in 
bringing about a speedy termination. So far as danger to life 
is concerned, this is usually considered almost nil. It should 
be remembered, however, that in exceptional instances exten- 
sion takes place both to the mastoid cells and to the middle 
ear, and that death has resulted from meningitis or sinus 
thrombosis. Occasionally dehiscences exist in the walls of 
the osseous meatus, rendering extension to the intracranial 
structures easy. It should also be remembered that after 
the contents of the abscess have been evacuated, either spon- 
taneously or by incision, a denuded surface remains, through 



226 CIRCUMSCRIBED EXTERNAL OTITIS. 

which infection may easily take place. The author has seen 
one instance of erysipelatous infection in this region, resulting 
in death. 

Treatment. — If observed early, our first efforts should be 
directed to abort the attack, if possible, and thus prevent pus 
formation. With this end in view, the local abstraction of 
blood by means of the natural leech, or better, perhaps, by the 
wet cup, should be instituted at once. If the area in front of 
the tragus is tender the blood should be abstracted from this 
region. In an adult two ounces of blood may be taken away 
if the wet cup is used; if the natural leeches are preferred, 
two or three may be applied directly in front of the tragus. 
When the posterior or superior wall is the site of the inflam- 
mation the best results are obtained by abstracting blood from 
the mastoid region. Owing to the free intercommunication 
of blood vessels in this region it is usually wise to take away 
a greater quantity here than when the leeches are applied 
in front of the tragus. With reference to the relative value 
of the wet cup and the natural leech, it should be stated that 
the wet cup is to be decidedly preferred, except perhaps in 
the case of children under six or seven years of age, who may 
object less forcibly to the natural leech than any instrumental 
procedure. If the natural leech is used, the meatus should 
be occluded with cotton to prevent the animal from attach- 
ing itself within the canal, an accident which has occurred in 
several instances. The chief objection to natural leeches is 
that in many cases they are difficult to apply, and the precise 
quantity of blood taken away can not be estimated. The re- 
sulting haemorrhage frequently continues for a considerable 
time after the leeches have been removed, and may be a source 
of annoyance both to the patient and his friends. Quite a num- 
ber of instances have been reported in which erysipelas has 
followed their application, a fact which certainly constitutes 
a grave objection. The wet cup, on the contrary, affords us 
a means of taking away the exact amount of blood we deem 
desirable ; it can be easily applied, and, if carefully done, its 
use is not attended by any more than trifling momentary pain. 
In very young children restraint will always be necessary 
whichever method is used, while adults almost invariably 
prefer to endure the momentary suffering which the artificial 
leech causes, rather than to subject themselves to the annoy- 
ance which the application of the natural leech entails. The 






TREATMENT— BLOODLETTING. 



227 



instrumental abstraction of blood may be effected by the use 
of a device which consists of a glass tube closed at one end, 
while the margin of the open extremity is ground accurately 
to permit of its exact application to the integument. The 
interior of the tube is fitted with an air-tight piston, the rod 
of which is provided with a thread. The other extremity of 
the tube is provided with a cap through which the piston rod 
passes. Beyond the cap the piston rod is provided with a 
nut w T hich traverses the thread upon the rod ; by turning this 
nut the piston is made to travel the length of the tube. 

If now the piston is lowered as much as possible, and the 
open extremity of the tube — previously smeared with a little 
vaseline — is applied closely to the skin, successive turns of 
the nut will exhaust the air from the tube and cause an in- 
tense congestion of the area which it covers, while the soft 
parts will bulge into the tube as the air above is rarefied, 
and the pressure of the air without will be sufficiently great 
to hold the apparatus in position. This process of dry cup- 
ping may of itself be sufficient in certain instances to relieve 
the symptoms ; if, however, it is decided to abstract a certain 
quantity of blood, the cup should be left in position for a 
few minutes, after which it should be removed and the local 
congested area punctured in several places, either by means 
of a small, sharp knife or by a scarificator, shown in Fig. 79. 




Fig. 79. — Bacon's scarificator. 

In either case the process is not painful, as the turgescence of 
the parts is so great that but little sensitiveness remains. The 
cup should now be quickly reapplied, when a free flow of 
blood follows, and as much may be removed as seems desira- 
ble. The application of this instrument would at first seem 
painful, on account of the local tenderness in the immediate 
vicinity of the ear ; it should be remembered, however, that 
local bloodletting is applicable only to the early stages 
of the disease, at which period this tenderness is not well 
marked. 

In place of the instrument mentioned above, the author 
employs one in which the scarification is performed without 



228 



CIRCUMSCRIBED EXTERNAL OTITIS. 





the removal of the cup, while the ordinary ear syringe is used 
to exhaust the air. Fig. 80 shows the method of operation, 
and renders a detailed description superfluous. The instru- 
ment is so constructed as to be interchangeable with the tip 

of the ear syringe, 
and thus the neces- 
sity of carrying a 
cumbersome appa- 
ratus is avoided. 

As before stated, 
local bloodletting is 
of value in aborting 
the affection only 
in the very early 
stages. When the 
pain has lasted for 
thirty-six or forty- 
eight hours before 
the patient is seen 
for the first time, 
this procedure will 
almost always be 
useless as a prophy- 
lactic measure, al- 
though it may tem- 
porarily relieve the 
pain ; usually, how- 
ever, it only adds 
to the discomfort 
which the patient 
is already suffering. 
After the abstraction of a certain amount of blood in the 
very early stages, the local application of cold is of undoubt- 
ed benefit, both for the relief of pain and for the purpose of 
aborting the attack. When the focus of inflammation is lo- 
cated upon the posterior wall of the canal, the application 
of cold may be made by means of the Leiter coil, shown in 
Fig. 81, the coil being so molded that it applies itself closely 
to the surface of the mastoid. The aural ice bag shown in 
Fig. 70 may also be employed for the same purpose. When 
the focus of inflammation is situated elsewhere, the coil be- 
hind the ear is of but little value, and, in order to be efficient, 



Fig. 80. — Author's artificial leech, 
adapted to the ordinary hard- 
rubber ear syringe. The piston- 
rod of the syringe is arranged 
with a bayonet catch to hold it in 
position when it is withdrawn, 
thus maintaining the vacuum. 



TREATMENT— COLD— INSTILLATIONS. 



229 



such an apparatus must be so arranged that a continuous 
stream of cold water is made to pass through a tube bent in 
the form of the letter U, and of such dimensions that it may 
be inserted into the auditory meatus. Theoretically, this is 
the ideal method of treatment; 
practically, it is of little value, for 
when the meatus is inflamed it is 
so tender that the presence of such 
an instrument causes considerable 
discomfort, and by its pressure 
aggravates the condition it is in- 
tended to relieve. Where the 
canal is large, however, the meth- 
od may be tried. 

The instillation of fluid prepa- 
rations to relieve the pain seems 
to me to be a measure of practi- 
cally no value whatever. A glance 
over the literature on the subject 
affords sufficient evidence of this, 
I think, on account of the large 
number of remedies which have 
been advocated. Thus we find 

recommended solutions of morphine, atropine, subacetate 
of lead, cocaine, menthol, oil of eucalyptus, dilute carbolic 
acid, veratrine, and, in fact, all the drugs of the pharma- 
copoeia which have a real or imagined analgesic local action. 
It must be remembered that the absorption of any remedy 
from the unbroken skin takes place very slowly and produces, 
therefore, when applied to the cutis, almost no effect aside 
from that due to the evaporation of the liquid, with the con- 
sequent production of a certain amount of cold. The small 
amount of benefit to be derived from such applications is 
more than counterbalanced, in my opinion, by the sodden 
condition of the epidermis, which is produced by the reten- 
tion of the liquid in the canal, making subsequent instru- 
mental manipulations much more difficult, and masking to a 
very great degree the local appearance upon speculum ex- 
amination. 

No remedies should be employed locally unless the epi- 
dermis has already been exfoliated over a considerable sur- 
face, a condition with which we not unfrequentlv meet as the 




The Leiter coil. 



230 



CIRCUMSCRIBED EXTERNAL OTITIS. 



result of a previous chronic inflammation. When this condi- 
tion is present, any of the before-mentioned drugs, either 
singly or in combination, may be beneficial. They are most 
conveniently used in the form of gelatin bougies, as advocated 
bv Gruber* under the name of amygdale aurium. They con- 
sist essentially of small conical suppositories of gelatin, the 
drug being incorporated in their substance; the heat of the 
canal dissolves the gelatin, and the drug is thus brought 
directly into contact with the walls of the canal and even 
distributed over the inflamed surface. Previous to their in- 
sertion the canal should be thoroughly cleansed with a mild 
antiseptic solution, after which the suppository is inserted and 
the orifice of the meatus closed by a small pledget of cotton. 
This method is certainly preferable to the use of oleaginous 
preparations, and may to an extent relieve the pain if the 
superficial epidermis has desquamated. Care should be taken, 
when any of the stronger alkaloids are used in the external 
meatus, to determine positively that no perforation of the 
membrana tympani is present, since when this condition exists 
absorption may rapidly take place, either from the mucous 
membrane of the middle ear or by passage of the drug into 
the pharynx and subsequently into the stomach — an event 
which would be followed by constitutional effects. If mor- 
phine is to be used, it should be in the form of the alkaloid 
itself and not in the form of one of the salts, since the simple 
alkaloid is more readily absorbed endermically than any of 
its combinations. The cocaine ear bath may relieve the local 
pain somewhat, after the exfoliation of the superficial laver 
of the epidermis, and is principally indicated where the sur- 
geon intends to incise the canal, in the course of a few hours, 
as the slow absorption may produce a certain amount of local 
anaesthesia. 

While cocaine is of great value as a local anaesthetic, its 
local analgesic action is somewhat limited, and for this pur- 
pose we may more advantageously employ an alcoholic solu- 
tion of menthol, dilute carbolic acid, creosote, oil of eucalyp- 
tus, thymol, oil of cloves, or some other aromatic oil. Of 
these remedies, menthol is perhaps the most efficacious in 
relieving the pain, which frequently is not confined to the 
ear, but may manifest itself as an intense neuralgia of the 

* Lehrbuch der Ohrenheilkunde, Vienna, 1888, p. 292. 



TREATMENT— HEAT. 



231 



various branches of the fifth nerve. This use of menthol was 
first advised by Cholewa.* 

In addition to the relief of pain, its action as a germi- 
cide makes it particularly valuable, as it affords a means of 
combating the local infective process and of preventing the 
formation of other abscesses. It is best applied by inserting 
into the canal a long, narrow pledget of cotton previously 
saturated with a ten- to twenty-per-cent solution of the drug 
in albolene or olive oil. The relief obtained is often consid- 
erable. The only objection to its use is the fatty vehicle with 
which it is incorporated. As the menthol is antiseptic, this 
is unimportant. It may be avoided by using an alcoholic 
solution of menthol in the manner above described, or a five- 
per-cent solution may be dropped into the canal at intervals. 
If, for any reason, we prefer to use carbolic acid or creosote, 
the preparations should not contain more than ten per cent of 
the drug. Menthol will probably prove of more value than 
any of the other drugs mentioned above. 

When a patient is observed at a stage too late for us to 
hope to abort the attack, the local abstraction of blood and 
the use of cold applications are worse than useless. The 
application of heat, however, is advantageous, as it relieves, 
to a very great degree, the intense suffering. Moist heat, 
however, is objectionable. The pernicious practice, so com- 
mon, of applying a poultice to the ear, or of putting the heart 
of a roast onion into the canal, the outer layers being applied 
to the outside to retain the heat, can not be too strongly con- 
demned. Such procedures favor the development of suc- 
cessive crops of furuncles by causing a maceration of the 
epidermis lining the canal, and aid subsequent local infection. 
While heat, therefore, is one of our most valuable agents, it 
should be employed as dry heat. This may be secured by 
filling an ordinary flat bottle with hot water, wrapping it in 
several layers of flannel, and resting the head upon it. A 
more elegant form of application is the small Japanese pocket 
stove which is sold in the shops, which when once lighted 
affords us a means of applying dry heat locallv, the small box 
being wrapped in flannel and either secured to the side of the 
head by means of a few turns of a bandage — its light weight 
rendering this practicable— or, after being enveloped in sev- 

* Therap. Monatsheft, 1SS9. No. 6. 



232 



CIRCUMSCRIBED EXTERNAL OTITIS. 



eral layers of cloth, it may be placed upon the pillow and the 
patient may rest the ear upon it. The common hot-water 
bag, found in every household, can be used in this manner, 
but its employment requires that the patient shall be continu- 
ally in the recumbent position, and this is sometimes undesir- 
able. In addition to these measures, if we wish to apply heat 
more directly to the parts, I sometimes direct patients to cut 
off the finger-tips of an old kid glove and fill them with salt, 
the open extremity being closed either with a few stitches or 
by a few turns of linen thread. These small salt bags may be 
warmed upon a common tin plate on a stove, or over a gas 
flame or oil lamp, after which they may be inserted into the 
meatus. The salt retains its heat for a considerable period, 
especially if the external parts are kept warm by resting the 
head upon a hot-water bag or similar device. 

Bearing in mind that the process is essentially one of local 
infection, our efforts should be directed, not only to the relief 
of the local condition, but to the prevention of the same in- 
fective process at other points in the canal. The canal should 
be thoroughly cleansed with a warm antiseptic solution by 
means of the syringe, using either carbolic acid, in the pro- 
portion of one to sixty, or the bichloride of mercury solution, 
about one to eight thousand. After syringing, which must 
be thoroughly but gently done, the ear is to be carefully 
dried with small pledgets of cotton rolled upon the cotton 
holder, the manipulation being conducted under ocular in- 
spection by means of reflected light. The canal should next 
be filled with an alcoholic solution of boric acid of the 
strength of twenty grains to the ounce. As the sensibility of 
the canal varies considerably in different subjects, the instilla- 
tion of alcohol may cause pain, and it is well to test the sensi- 
tiveness of the parts by touching the walls of the canal with a 
pledget of cotton previously moistened in the solution. If 
this causes pain the solution may be diluted with water, 
the quantity of water being rapidly diminished at each suc- 
cessive application as the sensitiveness of the parts becomes 
less. The instillation of this alcoholic solution should be re- 
peated at least four times during the twenty-four hours, and 
it is often advantageous to repeat it still more frequently. 
The syringing of the canal not only removes any discharge, 
together with exfoliated epithelial cells, but often relieves the 
pain to a very marked degree. Although frequent syringing 



TREATMENT— INCISION. 233 

of the canal is not advocated by the majority of writers, it 
has been my custom, especially in dispensary practice, to 
direct the patient to cleanse the ear in this manner several 
times daily, after which the alcoholic solution may be instilled 
in the manner already described. If the case is seen twice 
daily by the surgeon the patient need not use the syringe at 
home, but may instill the boric-acid solution without previous 
cleansing of the canal. It is seldom necessary for the surgeon 
to see the case as frequently as this, however, and equally 
good results are obtained if the canal is syringed by the pa- 
tient twice or three times daily, the alcoholic solution being 
used after each irrigation. The surgeon should, if possible, 
see the patient daily for the first few days. 

While all of these methods possess a certain amount of 
value the measure which stands pre-eminent in the treatment 
of this affection is that of early incision. To this, I think, we 
should always resort if our efforts to abort the attack by local 
bloodletting are not successful, or if the patient is seen at so 
late a stage as to preclude the possibility of it. It is not 
advisable to wait until the formation of pus has taken place, 
or even until local tumefaction is so extensive as to be easily 
recognized by ocular inspection. The process is most fre- 
quently deeply situated at first, and becomes superficial only 
a short time before spontaneous rupture occurs. Testing the 
walls of the canal by means of a cotton-tipped probe in the 
manner already described will enable the surgeon to recog- 
nize the affected area as certainly as if local tumefaction were 
present. The point of greatest tenderness should be incised 
deeply and freely with a sharp, short, strong, curved bistoury, 
the incision being carried through the perichondrium or peri- 
osteum, as the case may be. It must be of sufficient length to 
relieve all tension. This procedure is excessively painful — in 
fact, I know of no measure employed in surgery which causes 
such exquisite suffering as the early incision of a localized in- 
flammatory area in the canal, but the relief afforded fully jus- 
tifies the surgeon in inflicting this momentary pain. The 
beneficial results obtained depend not only upon the relief of 
tension, but also upon the very free bleeding which follows, 
this latter result being also beneficial in reducing the liability 
to the development of a similar condition in some other part 
of the canal. General anaesthesia is seldom required, as when 
a properly formed instrument is used it is only necessary to 



234 



CIRCUMSCRIBED EXTERNAL OTITIS. 




make the initial puncture under ocular inspection, the sur- 
geon being able to control the extent and direction of the 
incision by his tactile sense quite as well as by the sense of 
sight. The operation can be rendered painless by the ad- 
ministration of nitrous oxide, and as this anaesthetic causes 
no subsequent constitutional disturbance, it may be used 
with advantage. Local anaesthesia is of no value in these 
cases. 

After the focus of inflammation has been incised the 
rules already given concerning cleansing of the parts should 
be carried out, with the exception that any alcoholic solution 
applied to the canal must be considerably reduced in strength, 
as otherwise severe pain would be produced by its instilla- 
tion. The cleansing may be effected either by the ordinary 
ear syringe (Fig. 82), the small soft-rubber-ball syringe, or, if 
considerable pain persists, continuous irrigation of the canal 

may be employed. This 
may be carried out by 
using the ordinary foun- 

FlG." S2.-Hard-rubber ear syringe. tain Syringe. ^ A warm 

antiseptic solution, either 
of bichloride of mercury, one to eight thousand, or of boric 
acid, in the proportion of twenty grains to the ounce, may be 
allowed to flow over the parts continuously for a period of 
ten to twenty minutes. If this is done immediately after inci- 
sion, the attendant pain quickly disappears, while the warmth 
of the application favors free haemorrhage from the wound. 
This local depletion both relieves the pain and renders the 
reparative process more rapid. After free incision the relief 
is usually immediate, and in the course of twenty-four hours 
the parts assume more nearly their normal contour. The 
discharge, however, continues for a few days, during which 
time the infection of adjacent areas is very liable to take place 
unless attention is paid to the systematic cleansing of the 
parts, as above advised. Ordinarily the abscess cavity be- 
comes completely obliterated and the canal wall resumes a 
perfectly smooth and normal outline ; exceptionally, where 
the process has been very deep seated and a considerable area 
has been involved, exuberant granulations spring up about 
the margins of the opening. If very large, these may be re- 
moved by means of the cold snare or sharp curette. Usually, 
however, they are so small as to require simple cauterization 






TREATMENT— INTERNAL MEDICATION. 



235 



by a chemical agent. We may employ for this purpose either 
chromic acid or nitrate of silver, the former to be applied in 
substance, a minute bit of the acid being fused upon the tip 
of a metal probe and applied lightly to the efflorescent tissue, 
after this has been previously dried by a pledget of cotton ; 
any excess of acid must be immediately wiped away by means 
of a cotton-tipped probe, as otherwise the agent quickly 
spreads over the walls of the canal, and severe diffuse inflam- 
mation may result. The nitrate of silver may be used in the 
same manner, or may be applied as an aqueous solution of 
from two hundred and forty to four hundred and eighty 
grains to the ounce. I prefer the chromic acid, as in my 
hands, at least, it has never caused any reaction, while oc- 
casionally the silver preparations excite a severe secondary 
inflammation of the walls of the canal. If the destructive 
process has involved not only the integument, but also the 
underlying cartilaginous or bony structures, rather extensive 
necrosis may take place, retarding the healing process to a 
marked degree. In such an event it is well thoroughly to 
curette the cavity, removing all diseased tissue by means of 
the sharp spoon, after which rapid healing ensues. 

In addition to the local measures here advocated, the con- 
dition of the general health should always be borne in mind 
as furnishing a prominent predisposing cause of local disease. 
Especial attention should be paid to the gastro-intestinal canal ; 
constipation, if present, should be relieved, or disorders of the 
digestion corrected by the administration of alkalies or acids, 
as seem indicated. One of the most common causes under- 
lying this affection is simple anaemia. This is best combated 
by the use of some of the ferruginous preparations. Prob- 
ably no specific exists upon which we can depend to pro- 
duce any marked effect upon the progress of the local in- 
flammation. Sulphide of calcium, so much used in general 
furunculosis, has been frequently advocated, and for a con- 
siderable period I administered it regularly in every case, but 
was unable to perceive any beneficial results from its action. 
If its use seems indicated in any instance, it is best given in 
the form of a pill containing one sixth of a grain of the drug. 
One pill is to be taken every hour for six doses, after which 
the interval may be reduced to every two hours. After this 
medication has been continued for twenty-four or thirty-six 
hours the doses may be repeated less frequently, say at inter- 



236 CIRCUMSCRIBED EXTERNAL OTITIS. 

vals of every four or six hours. It will generally be found, 
however, to exert very little action upon the disease. The 
internal administration of drugs intended to relieve the in- 
tense suffering of the patient is always advisable in the very 
early stages. There can be no question that the relief of pain 
for a period of six or eight hours, when the process is in its 
incipiency, does exert a certain permanent beneficial action, 
the tendency being to increase the resisting power of the pa- 
tient. By relieving the pain or rendering it more bearable, 
our efforts toward aborting the attack will be more successful. 
It is to be borne in mind also that the pain will continue for 
only a comparatively short period of time ; hence, the admin- 
istration of opiates is not open to the objection that the pa- 
tient is liable to acquire the opium habit. In the later stages 
of the affection analgesics are contraindicated, as they may 
mask mastoid involvement. 

Chronic Circumscribed External Otitis. 

But few words need be said in consideration of a circum- 
scribed local inflammation of long duration. It is usually 
symptomatic of some affection of the deeper-seated struc- 
tures, either cartilaginous or bony. In the former instance 
it results from a very severe form of the disease just described, 
while in the latter case it is usually indicative of some patho- 
logical process within the mastoid cells, and is situated in the 
bony canal. The condition which clinically may be considered 
as belonging to this group, although from a pathological 
point of view it should be placed elsewhere, is that met with 
when suppuration takes place in the sebaceous cyst located 
in the meatus. These neoplasms usually occur on the an- 
terior or inferior walls of the canal, near the orifice, and either 
discharge spontaneously, or, if their contents have been evacu- 
ated by surgical means, persist for a long period, the lining 
membrane being of such a nature that adhesive inflammation 
with resultant obliteration of the sac is impossible. The 
cavity refills slowly after each evacuation of its contents, and 
the symptoms of obstruction of the meatus due to the pres- 
ence of the tumor, together with intermittent discharge at 
somewhat irregular intervals, are repeated for an indefinite 
period. Under these circumstances simple incision does no 
good, and will afford but temporary relief. The lining mem- 
brane of the sac must either be dissected out entire, or, if this 



CHRONIC CIRCUMSCRIBED EXTERNAL OTITIS. 



237 



is impossible on account of the location of the tumor, it must 
be completely destroyed by the curette, after which recovery 
is prompt. 

We shall consider circumscribed inflammation of the bony 
meatus dependent upon mastoid inflammation in the section 
devoted to mastoid disease. 



17 



CHAPTER XII. 

DIFFUSE EXTERNAL OTITIS. 

This affection may occur in either acute or chronic form, 
and, as its name implies, constitutes an inflammation of the ex- 
ternal auditory meatus, in which the local condition, instead of 
being- confined to a small area, involves either the entire canal 
or a very large portion of it, the line of demarcation between 
the normal and affected areas not being clearly marked, but 
merging gradually into each other. Since the acute form of 
the disease is frequently dependent for its cause upon a pre- 
viously existing chronic inflammatory process, we will con- 
sider, first, the chronic, and afterward the acute affection. 

Chronic Diffuse External Otitis. 

This general term applies to the superficial extent of the 
lesion rather than to its severity, and comprises every degree 
of chronic inflammatory condition of a diffuse character, from 
those cases in which only the superficial layer of the epider- 
mis is involved to instances where not only the cutaneous 
lining is affected through its entire depth, but the cartilagi- 
nous and bony framework as well. 

JEtiology. — This disease is less dependent upon constitu- 
tional conditions than is the circumscribed form of inflam- 
mation. Traumatism plays a very prominent part in its pro- 
duction. The impression so common among many that the 
external auditory meatus must be subjected to thorough 
cleansing by means of the corner of the towel wound up so 
as to permit its entrance into the lumen of the canal, or by the 
introduction of various ear sponges, ear spoons, etc., furnishes 
one of the most fruitful sources of mild but persistent inflam- 
matory conditions of diffuse character. Wounds of the canal 
walls, either inflicted by mechanical violence or resulting from 
the bites of insects which find their way into the meatus, are 
also among the most frequent causes of the disease. The ap- 

(238) 



yETIOLOGY— pathology. 



239 



plication of oleaginous substances to the walls of the canal, 
for the relief of pain in the ear, or sometimes for toothache, 
is practiced not uncommonly among the laity, and furnishes a 
source of irritation to the lining of the canal. Foreign bodies, 
introduced by mistake or design, by their presence alone fre- 
quently cause a condition of diffuse inflammation. The most 
common cause of the condition is some affection of the mid- 
dle ear attended by a purulent discharge. When the walls of 
the canal are continually bathed with such a secretion, they 
soon lose the superficial layer of epithelium through the com- 
bined action of warmth and moisture. Thus a denuded sur- 
face is left, through which infection may take place. This is 
more commonly met with among that class of individuals who 
pay little attention to habits of cleanliness, and hence make no 
effort to keep the passage free from secretion by frequent irri- 
gation. Among the more uncommon causes is the develop- 
ment of vegetable parasites within the canal. These minute 
organisms attach themselves firmly to the walls of the mea- 
tus, and grow for an indefinite period. As their growth con- 
tinues they become firmly imbedded in the deeper layers of 
the integument, and their removal results in the loss of the su- 
perficial epithelium and an exposure of the underlying cells. 
It is probable that the condition never engrafts itself upon a 
perfectly healthy integument — that is, one in which the horny 
layer of the skin is unbroken throughout the entire extent 
of the canal. If, however, the integument at any place is 
abraded, the moist surface forms an excellent soil for the de- 
velopment of a parasite. Having once taken root, the fungus 
may increase indefinitely by subsequent growth. The con- 
tinued presence of fungi produces an effect similar to that of 
a foreign body — that is, it causes an inflammation of the lining 
of the canal. 

Constitutional causes, we have said, are not important fac- 
tors in the production of this disease ; we make one excep- 
tion, however, in the case of eczema of the canal, which, like 
eczema in other parts of the body, is an evidence of some dia- 
thetic condition. 

Pathology. — An affection dependent upon such a variety 
of causes must necessarily present physical characteristics 
differing greatly. Under the milder types we would include 
those cases of augmented glandular activity resulting in an 
increase in amount of the secretion from the sebaceous follicles 



240 DIFFUSE EXTERNAL OTITIS. 

with which the skin is supplied. When the inflammation in- 
volves the inter-glandular tissue, as in eczema of the canal, 
there is a certain amount of infiltration of the deeper layers of 
the cutis, causing the superficial epithelium to be cast off more 
rapidly than under normal conditions. According to the de- 
gree of the infiltration of the integument, a greater or less 
amount of serum exudes, which, washing away the desqua- 
mated cells when the transudation is profuse, leaves a red, 
smooth, glistening surface ; or when less fluid is poured out it 
dries upon the walls of the meatus, forming with the desqua- 
mated epithelial cells yellowish crusts, which adhere to the 
canal walls and partially or completely occlude the passage. 
If the process is allowed to progress, actual hypertrophic 
changes take place in the basement membrane and the meatus 
is gradually converted into a tube of very small calibre, the 
opposing walls lying nearly in contact. An inflammation of 
the external canal occurring in the bony portion, where the 
cutaneous lining is very thin, and where it constitutes the peri- 
osteum, may extend to the osseous tissues and produce the 
symptoms which characterize an inflammation of the mastoid 
process, or, where the Rivinian segment is imperfectly closed, 
it may pass by continuity of structure into the tympanum and 
excite an inflammation within this cavity. 

When the inflammation of the canal is due to the presence 
of a foreign body, or follows a wound of the canal, a circum- 
scribed acute inflammation, or the development within the 
meatus of a vegetable parasite, the changes which take place 
vary in intensity, but are of the same character as those above 
described. The superficial epithelium is thrown off rapidly, 
the deeper layers of the cutis are infiltrated with round cells 
and become thickened, and tissue hypertrophy finally results. 
In the more severe cases tissue necrosis may take place or by 
extension the underlying bone may become involved. 

In some cases we find the activity of the inflammatory 
process directed especially toward a rapid proliferation of the 
superficial epithelial layer of the integument. The flat pave- 
ment cells are thrown off rapidly, and, aggregating in the mea- 
tus, form a compact mass, which completely fills the deeper 
portion of the canal. From the increase in the blood supply 
incident upon inflammation a small amount of serum is tran- 
suded ; the fluid moistens the compact epithelial mass and 
causes it to increase in volume. In this way great pressure 



PATHOLOGY. 



241 



is exerted upon the surrounding bony walls, which may be 
absorbed or become necrotic, or the pressure may be so grad- 
ual as to interfere but little with the nutrition of the parts, 
and result in a dilatation of the deeper portion of the meatus 
by crowding backward that part of the wall which separates 
the canal from the mastoid cells, so as to obliterate the pneu- 
matic spaces of this portion of the temporal bone. 

In the above consideration we have followed the extension 
of the process from the canal inward toward the deeper por- 
tions of the conducting channel. But a diffuse external otitis 
may be of a consecutive nature; that is, the deeper parts may 
be involved first, and by extension produce an inflammation 
of the walls of the meatus. This is particularly true where 
the deep osseous canal is the site affected. The upper and pos- 
terior portions of the canal at this point form the inferior or 
anterior walls of the mastoid process ; hence, an inflammation 
involving the mastoid antrum and the smaller pneumatic 
spaces frequently produces an inflammation of the canal in 
this region diffuse in character, the process being as much a 
mastoid periostitis as if the outer wall of the mastoid, lying 
immediately behind the ear, 
were the part affected. 

While it lies beyond the 
province of this work to give 
any detailed account of the 
microscopic appearances of 
the various forms of vegeta- 
ble parasites found in the 
meatus, certain characteris- 
tics which are common to 
all of these should be under- 
stood, in order that a diag- 
nosis may be made between 
the purely epithelial or des- 
quamative type of inflamma- 
tion and that form dependent 
upon the presence of fungi. 
These fungi present under 
the microscope long fibres or hyphae of a double contour. 
either completely transparent or slightly granular. Those 
fibres divide into branches dichotomously (Fig. 83), which 
terminate in a globular head or fruit-sac (sporangium) (Fig. 84) 




Fig. 83. — Development of a fungus, u, u, 
Sporangia ; H, Hyphse. (G ruber.) 



:_: 



:x* 



r\a; 



filled with minute spherical sf :res. Examination of the fruit- 
sac at a certain stage :: development will show thin filame: ts 
radiating from a central stalk toward the periphery through 
the mass of minute se ires. These fresh filaments in turn 





Fig. S-|_ — Microscopical characteristics of otomycosis. 
_ : _ : . Sporangia ; If, Hyphae. (Gmber.) 

develop sporangia, and tae process retreats itself indefinitely 
The recognition, then, of the mycelial filaments or of the 

iruit-aeaas emtaimrg- the sr :-res establishes the fhagrisis :: 
parasitic inflammation. 

Symptomatology. — The symptoms differ in severity in ac- 
cordance with the degree of intensity of the local process. In 
mild cases a sense of constant irritation or itching in the canal 
is the most prominent symptom, the patient continually at- 
tempting to relieve this bv the insertion of the tip of the little 
finger as far into the meatus as possible : this, naturally, only 
tends to aggravate the condition it is intended to relieve. 
When either from increased glandular activity, as in sebor- 
rhoea, or from actual inflammation, as in eczema or otomyc : sis. 
the canal becomes to an extent occluded, either by the scale- 
like sebaceous crusts, :r by a^rregaations of epithelium re- 
sulting from eczema, :r by masses ::' vegetable fungi, certain 
svmptoms dependent upon this occlusion manifest themseives. 
These may consist in an impairment of the hearing, varying 
in degree according to the extent of obstruction, or there may 
be tinnitus caused by the congestion which the presence of the 



SYMPTOMATOLOGY. 243 

foreign substance induces, or certain reflex symptoms may 
manifest themselves, such as severe pain spreading over the 
distribution of the fifth nerve, headache, either general or 
local, and, rarely, disturbances of a graver nature, dispropor- 
tionate in severity to the local condition. Thus, instances of 
epileptiform attacks have been traced to inflammatory condi- 
tions within the canal, while symptoms referable to the oppo- 
site ear may also be produced by a chronic inflammation of 
the external auditory meatus of one side. A symptom fre- 
quently complained of is that of autophony, the patient's own 
voice seeming to come from the affected side. This occurs 
only when the lumen of the canal is considerably narrowed. 

Cough is a not infrequent symptom of the affection, and 
may, in fact, be the first to attract the attention of the patient 
and cause him to seek advice. In all cases of cough, even al- 
though apparently explainable upon other causes, it is always 
well to examine the external auditory meatus, as an accumu- 
lation of any foreign material, resulting either from desquama- 
tion of the epithelial lining of the canal or from the aggrega- 
tion of a mass of aspergillus, may cause a reflex cough. As 
the affection increases in severity a discharge may make its 
appearance at the orifice of the meatus. This discharge is 
ordinarily scanty, and, in fact, may be so small in amount as to 
appear in the form of crusts about the margin of the meatus, 
the fluid elements having been evaporated. When more pro- 
fuse the discharge is watery in character, but is never large 
in amount. In the milder cases, due to an inflammation of the 
glandular structures alone, the discharge appears in the form 
of minute scales, which are oily to the touch, on account of the 
fatty matters which they contain. Occasionally, in cases of 
very long duration, the inflammation, instead of producing a 
fluid discharge, causes a proliferation of the epithelial lining 
of the meatus. The superficial epithelial cells are rapidly cast 
off, and, aggregating into masses, remain in the canal for a long 
period. These masses of desquamated epithelium absorb the 
watery secretion which the thickened cutaneous lining of the 
canal exudes, and as the process continues increase steadily in 
size. From the fact of their slow increase in volume these 
epithelial plugs exert a great amount of pressure upon the 
walls of the canal, leading, in some cases, to a dilatation of the 
bony canal, either bv causing an absorption of the osseous tis- 
sue or by crowding the thin bony wall upward and outward 



244 DIFFUSE EXTERNAL OTITIS. 

toward the mastoid cells, which become correspondingly di- 
minished in size. At the same time the osseous tissue under- 
goes certain structural changes as the result of this mechanical 
irritation, so that, instead of presenting the ordinary cancellous 
appearance, it becomes converted into a hard, ivory-like sub- 
stance of uniform density. This change may extend through- 
out the entire mastoid, all the air spaces being obliterated with 
the exception of the antrum, or, if the pressure is still greater, 
the bony walls of the canal may be absorbed entirely, and the 
upper part of the tympanic cavity and the mastoid cells may 
thus be continuous with the external auditory meatus. 

Glandular enlargement is not uncommon as the result of 
chronic inflammation of the external meatus, and when the 
glands just below the lobule are affected a mistake in diagno- 
sis is possible, the case presenting many of the characteristics 
of a perforation through the tip of the mastoid process. 

We have spoken of dilatation of the bony canal as the re- 
sult of a desquamative inflammation with the consequent ab- 
sorption or displacement of the bony walls. The opposite 
effect may be produced, however, if, instead of causing a des- 
quamation of the superficial epithelium, the deeper layers of 
the integument are the seat of inflammation ; in these cases, 
the lumen of the canal may become very narrow — in fact, it 
may be so diminished in size as to admit only the smallest 
probe. This diminution in calibre is due to an actual hyper- 
trophic osteitis rather than to any thickening in the soft parts. 
This change frequently takes place in the cases of diffuse ex- 
ternal otitis which accompany a chronic suppurative process 
within the middle ear. Instead of narrowing the calibre of 
the canal uniformly, certain limited areas within the canal 
may be affected, producing what is known as an exostosis or 
a circumscribed bony growth, which projects to a greater 
or less extent into the passage. These growths are most fre- 
quently situated near the drum membrane, and, according to 
their size, interfere with the function of audition. 

Diagnosis. — The diagnosis of chronic diffuse external otitis 
will be determined both by external manipulation and by ex- 
amination by means of the speculum. We have to distinguish 
by palpation between an affection confined to the canal and 
one involving the mastoid process, as the superior and a por- 
tion of the posterior walls of the meatus form the anterior and 
inferior wall of the mastoid process. It would seem that this. 



DIAGNOSIS. 245. 

differentiation is rather superfluous, but the author intends 
here to separate those cases in which the affection of the canal 
is the prominent feature, the mastoid being involved to so 
slight an extent as to give rise to no symptoms and to require 
the employment of no special measures, from those cases in 
which the affection of the canal is merely symptomatic of a 
deep-seated inflammation within the mastoid, in which treat- 
ment must be directed to the mastoid inflammation as the pri- 
mary disease. When the affection is confined to the canal, 
pressure behind the ear, directed backward and inward, will 
fail to elicit tenderness ; if the pressure is exerted in such a 
way as to move the fibro-cartilaginous meatus, very marked 
tenderness will be elicited. In the same way pressure from 
below, above, or in front of the canal will cause more pain 
than if made directly over the mastoid process. The appear- 
ance presented upon inspection by reflected light will vary 
according to the cause and character of the affection, as well 
as with its intensity. In the milder cases, under which we in- 
clude seborrhcea, eczema, and a chronic otitis externa diffusa 
caused by an aspergillus, inspection will show that the walls 
of the canal are covered either partially or completely with 
some foreign substance. In seborrhcea this will be confined 
almost entirely to the cartilaginous meatus, and the deposit 
will appear to be made up of small, thin, yellowish crusts 
which are easily detached and upon compression between 
the finger and thumb have an oily feel. The surface from 
which these small scales are detached is somewhat reddened, 
but not moist. In eczema the crusts are larger, adhere more 
closely to the walls of the meatus, and are evidently made up 
of desquamated cells which have been moistened with serum 
and have become agglutinated into a mass. This collection 
of cast-off cells has subsequently dried into thick, irregular, 
yellowish-brown crusts. Here the affection extends from just 
within the orifice of the meatus to the drum membrane itself ; 
the crusts are detached with some difficulty, their former lo- 
cation presenting as a red, moist area, which, upon being dried 
with a cotton pledget, quickly becomes coated with a thin 
serous transudate. Inspection and tactile manipulation bv 
means of the probe demonstrate an evident thickening of the 
deeper layers of the cutis of the canal. 

In the milder forms of aspergillus the canal walls arc cov- 
ered, sometimes throughout their entire extent, at other times 



246 



DIFFUSE EXTERNAL OTITIS. 



only here and there, by a whitish or yellowish-white deposit, 
which seems to be closely adherent to the underlying struc- 
tures (Fig. 85). The entire lumen of the canal may appear 
somewhat narrow. Upon using the cotton holder to wipe 
out the meatus, in order that inspection may be more exact, 
the parts may be found to be moist, the instrument removing 
from the walls of the canal, in addition to the moisture which 
it has absorbed, thin, moist flakes or scales, usually of a whit- 
ish color, the surface from 
which they were removed 
appearing denuded. Upon 
attempting thoroughly to 
clear the canal it will often 
be found possible to de- 
tach relatively large thin 
sheets of this deposit, of a 
white or a dirty yellowish- 
brown color, having the 
consistency of moistened 
paper. In this way a com- 
plete cast of the canal from 
the very orifice of the mea- 
tus may be obtained. If the 
process has spread to the 
drum membrane the cast 
will form a blind sac, the 
closed extremity bearing the imprint of the various landmarks 
of the membrana tympani. This deposit is due to the growth 
of low vegetable organisms upon the walls of the meatus. The 
special species of plant life can only be determined by micro- 
scopic investigation ; the varieties met with are extremely 
numerous, but as the treatment of the different forms does 
not vary essentially it is unimportant to discuss the condition 
at length in a treatise devoted particularly to clinical otology. 
Certain macroscopic features, however, enable us to make a 
reasonably accurate diagnosis as to the particular variety of 
plant present in a given case. A white deposit usually con- 
sists of the aspergillus glaucus. Another variety is the asper- 
gillus flavus, the microscopic features of which are shown in 
Fig. 86, while more rarely we find the walls of the canal and 
the surfaces of the membrane covered with irregular black 
spots, a little smaller than the head of a pin, which are the 




Fig. 85. — Otomycosis. The canal is lined 
with a thin deposit which covers the 
walls and the surface of the membrana 
tympani. The punctate areas on the 
membrana are caused by the increased 
growth of the fungus in these situations. 
(Natural size.) 



DIAGNOSIS. 



247 



sporangia of the aspergillus niger. The growth of this latter 
is seldom as extensive as that of the other two varieties. A 
microscopic examination alone will enable us to distinguish 
with certainty between otomycosis and the milder forms of 
desquamative inflammation involving the canal. The greater 
consistency of the epithelial plug and the imbricated arrange- 
ment of the scales usually give the observer a hint as to the 
nature of the condition present. It is probable that in no 
case do these low forms of 
vegetable life take root upon a 
perfectly healthy cutaneous sur- 
face ; it is necessary that the 
epithelium should be wanting 
over a small area at least, in 
order that the plant may de- 
velop. Hence it is, that para- 
sitic inflammation of the mea- 
tus is usually coexistent with 
some condition of the external 
canal or of the middle ear char- 
acterized by the presence of 
moisture. The epithelium of 
the canal is thus softened and 
thrown off, leaving a surface 
which forms an excellent site 
for the development of a low form of plant life, the growth 
being stimulated at the same time by the presence of moisture. 
The mere presence of aspergillus spores in any aggregation 
of foreign matter which may be removed from the meatus does 
not warrant a diagnosis of parasitic inflammation of the canal, 
since it is usual to find them in ceruminous masses, or upon 
any foreign body which has remained in the canal for a con- 
siderable length of time. It is only when they constitute the 
bulk of the mass that this constitutes a lesion proper. 

The diagnosis of the desquamative form of inflammation 
will be based upon the presence in the deep meatus, of a com- 
pact mass, whitish in color, which, although easily penetrated 
by the probe or curette, is removed with considerable diffi- 
culty. The walls of the canal are ordinarily moist and pre- 
sent a sodden appearance, the superficial epithelium being 
easily wiped off by means of the cotton pledget, which, upon 
investigation, is found to be covered with thin white flakes of 




Fig. 86. — Aspergillus flavus. 
G, Sporangium ; H, Hypha. (Gruber.) 



248 DIFFUSE EXTERNAL OTITIS. 

irregular size and shape. If the probe is immersed in water 
these are seen to spread out and float upon the surface, but 
are not dissolved by the fluid ; they are really the epidermal 
cells lining the canal, which have been thrown off by the in- 
flammatory process. The obstructing mass is an aggregation 
of these cells, and, though easily penetrated by any instru- 
ment, which may remove a considerable quantity each time 
it is inserted, is very difficult to remove completely. Even 
when the fundus seems entirely clear we often find, in at- 
tempting to dry the parts perfectly, that the cotton pledget 
brings away more of these white scales, so that the complete 
clearing out of the meatus is a matter of no small difficulty. 
The entire epithelial plug presents an appearance not unlike 
a wad of unsized paper that has been moistened in water, and, 
in fact, is often mistaken for a foreign body of this kind, which 
has found its way into the canal. 

Where the inflammation is of what may be called the 
symptomatic type — that is, merely an indication of a deeper- 
seated inflammatory process within the mastoid — we usually 
find that the superior and posterior walls of the canal close to 
the membrana tympani are most involved. The canal lumen 
at its deepest part is narrowed by an apparent sinking of the 
walls, and at the fundus, instead of a well-defined line of de- 
marcation between the drum membrane and canal walls, it ap- 
pears as if the superior and inferior walls were separated only 
by a narrow slit, through which a small area of the membrane 
is seen. The chief point of diagnostic importance is the dif- 
ference between this condition and that seen in circumscribed 
otitis externa. In this latter form, after the speculum has been 
introduced into the canal, the membrana tympani is distinctly 
seen, and appears normal in extent as the obstruction lies near 
the orifice of the meatus. In the disease under consideration 
the introduction of the speculum is easy, but the canal be- 
comes more obstructed as we approach the fundus, owing to 
the fact that the disease is a periostitis of the deeper part of 
the canal (Fig. 78). It is of extreme importance, especially in 
children, to recognize this condition early, as it is one of the 
best indications that a previously existing middle-ear inflam- 
mation has involved the deeper structures, or that an accumu- 
lation of pus in the tympanum has passed out through the 
Rivinian fissure along the superior and posterior aspects of 
the meatus (Fig. 87). In either case the condition is one 



PROGNOSIS. 



249 




- / 



which requires prompt treatment in order that serious con- 
sequences may be averted. The appearance presented by a 
chronic diffuse otitis, resulting- in either uniform narrowing of 
the meatus or isolated bony 
deposits or exostoses, offers 
no difficulties in diagnosis. 
When the latter condition is 
present, care need only be 
taken to so cleanse the parts 
that the observer may be cer- 
tain that the localized en- 
croachment upon the lumen 
of the canal is beneath the 
integument instead of super- 
ficial to it. It would seem al- 
most impossible for this mis- 
take to be made, but masses of 
hardened cerumen occasion- 
ally present the appearance 
of an exostosis, the surface of 
which is covered by a thin 
layer of cerumen. By means 
of the curette any foreign substance is easily removed from the 
canal wall, and the true condition becomes apparent at once. 

Prognosis. — The course pursued by the disease we are 
here considering is as varied as the causes which underlie it. 
The simpler varieties are unattended by any grave results, al- 
though somewhat obstinate to relieve. Where the deeper 
parts are involved, where the disease is of long- standing-, or 
where the condition is symptomatic, the prognosis is fre- 
quently grave. Important regions may suffer secondarily, 
by extension directly from the canal, or the condition with- 
in the meatus may, if unchecked, spread to the middle ear 
and result in any of the sequelae of a severe inflammation with- 
in the tympanum. Where the disease is secondary to an in- 
tratympanic affection the gravity of the prognosis depends 
more upon the condition of the middle ear than upon the 
changes within the canal. As regards the impairment of 
function, the power of audition may suffer either from the 
narrowing- of the meatus throughout its entire extent or bv 
the development of circumscribed bony deposits. In some 
instances the chronic congestion of the deeper structures 



Fig. 87. — Appearance observed in infancy 
when fluid from the tympanum escapes 
through the Rivinian fissure. (Nat- 
ural size.) 



250 DIFFUSE EXTERNAL OTITIS. 

caused by a chronic inflammatory process within the mea- 
tus, may lead to functional impairment. In the desquama- 
tive form of inflammation the pressure exerted by a mass of 
epithelium may produce fatal results by absorption of the 
bony walls and exposure of the cranial contents. This may 
occur without any symptoms of middle-ear inflammation, or 
the membrana tympani may be destroyed and a suppurative 
otitis media result. Sometimes the mass, while not leading to 
such grave results, seriously impairs the function of the ear 
by chronic adhesive processes within the tympanum from the 
long-continued pressure. In other cases the pressure causes 
labyrinthine changes. 

Treatment. — In the mild cases of chronic diffuse otitis 
externa treatment is largely directed to the relief of the dis- 
tressing pruritus from which the patient suffers. The crusts 
arising either from involvement of the sebaceous glands in 
seborrhcea or from cutaneous infiltration in eczema should 
be removed by some bland oily application, such as vaseline 
or olive oil, after which, in the glandular variety of the dis- 
ease, it will be sufficient to apply once each day a slightly 
stimulating ointment, such as the unguent, hydrarg. ammoniat., 
diluted with ten parts of vaseline or cold cream, or the un- 
guent, hydrarg. oxidi flavi may be employed in about the 
same strength. In eczema the various measures detailed 
under eczema of the auricle will be found valuable. It is im- 
portant, in order that the treatment may be efficacious, that 
the patient should refrain from scratching the ears, as this 
increases the local inflammation. For this purpose we may 
add either cocaine or morphine to the above ointments. It 
is well for these patients on retiring to insert into the ear a 
pledget of cotton smeared with such an ointment, as they 
frequently injure the parts during sleep. The use of water in 
any inflammatory condition of the canal attended with infil- 
tration of the integument is to be absolutely forbidden, as it 
tends to increase its activity. 

In the parasitic variety the fungus should be removed as 
completely as possible by means of the curette, forceps and 
cotton pledget, great care being taken to avoid abrading the 
epidermis of the canal. In these cases the walls of the mea- 
tus will be found very sensitive, and the complete removal of 
the parasite will be difficult. The occasional application of a 
ten per cent, solution of cocaine during the operation will af- 



TREATMENT. 25 I 

ford considerable relief and will facilitate the operation. It 
is not well to prolong unduly our efforts at removal or to in- 
flict severe pain. After as much as possible has been removed 
a solution of bichloride of mercury, one to eight thousand, in 
fifty per cent alcohol, or a saturated alcoholic solution of bo- 
racic acid, or a two-per-cent alcoholic solution of salicylic 
acid, as Siebenmann* recommends, should be applied to the 
parts by means of the cotton pledget. 

It is sometimes well to employ a powder instead of the 
above ♦solutions. The walls of the canal may be lightly dusted 
with boracic acid or a mixture of boracic acid and salicylic 
acid in the proportion of twenty to one. In this way we 
avoid the presence of moisture, a condition which we know 
favors the growth of the fungus. It is well to see the patient 
daily at first, and at each sitting to remove as much of the 
deposit as possible. When the canal seems free the antisep- 
tic solution should be placed in the hands of the patient, and 
he should be directed to instill ten or twelve drops of either 
preparation into the canal twice or three times daily. By 
this means any new growth is prevented and a complete cure 
effected. Remembering that an otomycosis is often depend- 
ent upon a suppurative inflammation of the middle ear, it is 
scarcely necessary to state that this affection, if present, must 
be treated properly in order to prevent the recurrence of the 
condition. 

Prophylactic measures against development of organisms 
within the meatus should be taken in all cases of aural disease 
which come under the observation of the surgeon. A com- 
mon cause of the milder varieties of this affection depends 
upon a habit so common among the laity of instilling oily so- 
lutions into the ear for the relief of pain. Not only should 
this be forbidden, but the surgeon should be particularh- care- 
ful in cases where it is necessary to use oily substances within 
the meatus that none of the fatty material remains in the canal 
when the patient is discharged. To be certain of this it is ad- 
visable upon dismissing the patient to wipe the canal thor- 
oughly with a cotton pledget moistened in alcohol. 

In the desquamative form, the first indication is to remove 
the mass of epithelium filling the canal. This is bv no moans 
simple where the disease has persisted for a long time, espe- 

*Arch. of Otol., vol. xviii, p. 235. 



.252 



DIFFUSE EXTERNAL OTITIS. 



cially as attention is frequently drawn to the condition for the 
first time by an acute inflammation of the parts, resulting in 
so much swelling that the calibre of the canal is greatly 
reduced. 

Our first efforts at removal should be by the use of a warm 
antiseptic solution injected into the ear by means of the syringe. 
This will usually bring away the superficial portion of the 
mass, and occasionally all of it. Frequently, however, the 
deeper portion of the canal remains obstructed, and it will be 
necessary to use the blunt curette in order completely to re- 
move the collection. When the canal is swollen and tender, 
as frequently occurs from an acute exacerbation, the manipu- 
lation is extremely difficult, and sometimes a general anaes- 
thetic is necessary. In using the curette, we should first at- 
tempt to separate the mass from the canal along one wall, 
and afterward break it up by inserting the instrument be- 
tween it and the canal wall and removing small portions suc- 
cessively until a narrow channel has been made between the 
canal wall and the foreign body. By directing the stream of 
water from the syringe toward this channel, the entire mass 
may usually be brought away, although it may be necessary 
to remove the entire collection piecemeal with the curette. 
If it is impossible to insert the curette between the epithelial 
aggregation and the canal wall at any point, owing to the ten- 
derness of the meatus, our efforts are sometimes more success- 
ful if a passage is tunneled directly through the centre of the 
plug, after which, by carrying the curette into this channel 
and then pressing it in toward the opposite wall of the canal, 
the portion included between the instrument and the wall 
may be removed ; the process must be repeated until the mea- 
tus is perfectly clear. 

Where the condition has remained unrecognized for a long 
time, the bony meatus close to the drum membrane may be 
very much dilated, and the foreign body attain such dimen- 
sions as to render its removal from the meatus in its entirety 
impossible. At the same time the deep meatus has been so 
dilated that the manipulation of any instrument, such as the 
curette or a spoon, is very much restricted. These epithelial 
masses may invade the cells of the mastoid process through 
the absorption or necrosis of the bony walls from pressure. 
It occasionally becomes necessary to open the mastoid in 
order completely to eradicate the disease. Such cases have 



TREATMENT 253 

been reported, but an element of doubt always remains as to 
whether they were not cases of cholesteatoma originating 
within the tympanum and invading the canal secondarily. 

After the canal has been thoroughly cleared, our efforts 
should next be directed toward putting the epidermis in 
normal condition. Here powders are of special benefit, as 
they relieve the sodden condition of the parts more quickly 
than do fluid preparations. For this purpose boracic acid 
may be dusted over the walls of the canal, or a mixture of 
boracic acid and iodoform, or iodol, if the odor of iodoform 
is objectionable. Quite recently the introduction of dermatol 
into surgery has given us a drug particularly adapted to these 
cases. These measures should not be trusted to the hands 
of the patient, but should be carried out by the surgeon — at 
first daily, the interval being increased as the case progresses. 
The oxide of zinc mixed with boric acid, in the proportion 
of one part of oxide of zinc to two of boric acid, may also 
be used with advantage in the milder forms of the disease. 
When necrosis has occurred it will first be necessary to re- 
move the dead bone, after which the case may be managed 
on general surgical principles. If granulation tissue develops, 
a thorough cleansing of the parts may be sufficient to cause 
it to disappear ; if large in amount, it should be removed 
by means of the cold snare or destroyed in situ by the gal- 
vano-cautery, nitrate of silver, or chromic acid. The last 
agent yields better results and is more easily manipulated 
than the others. 

Where the disease is of the symptomatic variety much 
more energetic measures must be undertaken, and if the pain 
is intense, cold applications to the mastoid process are indi- 
cated. This is most easily effected by using the Leiter coil 
(Fig. 81) or the aural ice bag (Fig. 70). The local abstrac- 
tion of blood by means of the artificial leech may also give 
relief where the pain is very severe. It is to be applied be- 
hind the ear over the mastoid process, since the symptomatic 
variety is indicative of the fact that this region is affected. 
From a healthy adult from two to four ounces of blood may 
be removed ; and in the very early stages this plan of local 
bloodletting, followed by the application of cold, may pre- 
vent further progress. If this fails, or if the condition has 
advanced too far to be aborted, a long deep incision should 
be made through the tumefied tissues which are seen to 



254 



DIFFUSE EXTERNAL 'OTITIS. 



encroach upon the lumen of the canal close to the membrana 
tympani. This incision completely divides the soft parts 
down to the bone. The short curved bistoury is carried into 
the canal as far as the drum membrane, and is plunged 
quickly into the bulging supero-posterior wall until the point 
is felt to impinge upon the bone ; it is then drawn outward, 
the point still being pressed firmly upon the bone. In this 
way the periosteum is divided and tension relieved. The in- 
cision should not be less than half an inch in length, and may 
be even longer ; the bleeding is very free, a fact which con- 
tributes largely to the benefit derived. It is to be borne in 
mind that the external otitis here is a manifestation of an 
inflammatory process within the upper part of the tympanum 
itself. We are therefore, in making the initial puncture, to* 
carry the knife upward, backward, and inward beyond the 
inner extremity of the bony canal, through the membrana 
flaccida, into the tympanic vault (Fig. 87). The incision is 
completed in the manner above described by drawing the 
knife outward along the supero-posterior wall of the meatus. 
In this way the mucous folds within the tympanum are di- 
vided, and the congestion within the middle ear reduced. 
Where the tumefaction in the canal is due to the presence of 
pus, evacuation through the meatus is not sufficient, and it is 
imperative that the mastoid cells should be at once opened 
and every vestige of diseased bone removed. 

Where the inflammation has led to a diminution in the 
calibre of the meatus through hypertrophy of the bony walls, 
it is sometimes necessary, in order that the function of the 
organ may be preserved, to attempt a restoration of the 
channel to its normal size. When a very small passage re- 
mains, gradual dilatation, if systematically carried out for a 
long time, may prove satisfactory. This is best accomplished 
by inserting into the canal a small aluminium tube, which will 
just pass through the constriction. The patient is to wear this 
for one or two days, when it is to be removed and a little 
larger tube inserted. It is seldom possible, however, to 
promise that the tube may ever be dispensed with perma- 
nently, for when it is removed the parts very quickly resume 
their original position. The diameter of the meatus may be 
very considerably increased by carrying out this treatment, 
and the patient should learn to insert the tube himself, wear- 
ing it during the day and removing it at night. Its presence 



ACUTE DIFFUSE EXTERNAL OTITIS. 255 

causes no inconvenience, and effectually relieves the impair- 
ment of hearing due to the diminished size of the passage. 
Pomeroy has suggested the use of small rubber tubes stretched 
over a silver probe to enable them to be inserted through the 
stricture. After they have been properly placed the probe is 
withdrawn and the tube resumes its original dimensions, thus 
exerting by its elasticity a constant dilating force against the 
surrounding walls. This plan has proved advantageous in 
some cases, but relapses have taken place, even after the con- 
dition was apparently cured. Where the channel is so nar- 
row that only a fine probe can be passed, and the use of a 
tube is impossible, it is well, for the first few days, to carry 
a very small, tightly wound pledget of cotton through the 
constriction by means of the forceps ; this cotton pledget ab- 
sorbs moisture from the walls of the canal, increases in size, 
and dilates the passage slightly. In this way sufficient space 
may be gained to permit the insertion of a small tube, after 
which one of the plans already described may be carried out. 
The removal of any portion of the bony wall by means of 
cutting instruments is seldom attended by good results where 
the narrowing is symmetrical. If the passage is encroached 
upon by an exostosis, this may be removed. This condition 
will be treated in a later chapter. 

Acute Diffuse External Otitis. 

^Etiology. — The acute form of the disease usually occurs 
as an exacerbation of a previous chronic condition ; occasion- 
ally, however, it presents as an idiopathic disease, either from 
exposure to cold or as a complication of some profound con- 
stitutional infection, as epidemic influenza, scarlet fever, typhus 
and typhoid fevers, etc. The most frequent cause is a puru- 
lent otitis media, the tissues of the canal becoming infected by 
the purulent discharge in which they are bathed. This last va- 
riety does not include those cases already denominated under 
the term symptomatic. Injuries of the canal from mechanical 
violence or from the action of the potential or chemical escha- 
rotic agents may also give rise to an acute diffuse inflamma- 
tion of the parts. An occasional cause is the occurrence of a 
furuncle in the meatus, the condition becoming general and 
involving the entire canal after the circumscribed process has 
fully developed. 

Pathology. — The changes consist in a diffuse inflammation 



256 DIFFUSE EXTERNAL OTITIS. 

of the cellular tissue of the walls of the meatus. In the first 
stage the parts are intensely congested, after which there is a 
free transudation of the fluid elements of the blood, causing 
oedema ; the interstices between the connective-tissue fibres 
become infiltrated with new cells, and if allowed to continue 
unchecked pus formation results. It is seldom, however, that 
this occurs, as relief is sought before this stage is reached. 
The tissues break down in this region at a very late period, 
on account of their density and firmness, and remain infiltrated 
for a long period before local necrosis results. 

Symptomatology. — The subjective S3 T mptoms are pro- 
nounced and succeed each other rapidly. The first sensation 
is one of fullness or discomfort in the canal, quickly followed 
by intense pain. The constitutional disturbance is frequently 
quite marked, the temperature being elevated from two to 
three degrees above normal ; considerable prostration is pres- 
ent ; the patient suffers from headache, loss of appetite, and all 
those symptoms indicative of an inflammatory process in dense 
cellular tissue. From the swelling of the parts the meatus is 
rapidly occluded and the function of audition is markedly in- 
terfered with. Subjective noises are often present, but the 
pain is so severe that they are seldom complained of. In ad- 
dition to the spontaneous pain intense pain is elicited upon 
touching the auricle. After a short period the surrounding 
lymphatic glands may become infiltrated, especially those ly- 
ing immediately behind and below the auricle, any movement 
of the jaws is painful, and in severe cases the mouth is opened 
with difficulty. 

Diagnosis. — We have to differentiate between a circum- 
scribed inflammation of the meatus, an acute affection of the 
middle ear and mastoid, and the disease under consideration. 
The symptoms complained of by the patient do not differ, ex- 
cept in severity, from those characteristic of the circumscribed 
external otitis. The constitutional disturbance, however, is 
much more marked and the progress of the disease more rapid. 
The insertion of the speculum ordinarily causes but little 
pain and the outer third of the meatus is often found to be 
nearly normal in size. Deeper, however, the lumen is much 
diminished, the encroachment usually being from the supero- 
posterior wall, which seems to project downward and for- 
ward into the canal. The swelling is more pronounced as 
we approach the fundus and a considerable portion of the 



DIAGNOSIS. 



257 



drum membrane is hidden from view. Where the membrana 
tympani lies very obliquely to the superior and posterior walls 
it apparently merges into these without any line of demarca- 
tion. This is particularly the case in infants, owing to the ab- 
sence of the bony meatus ; in the adult, however, if the canal 
alone is involved the observer recognizes that a portion of the 
drum membrane is concealed from view, but that the swollen 
wall of the canal is not continuous with the membrana tym- 
pani (Fig. 88). A sulcus can be recognized between the mem- 
brana tympani and the tumefaction. In very severe cases 
the swelling may be so great as to occlude the meatus com- 
pletely, the opposite walls lying in contact. The surface of 
the tumefaction is slightly 
moist, presenting a dead- 
white color, due to the local 
necrosis of the superficial 
epithelial cells. If these are 
wiped away the surface ap- 
pears reddened and moist. 
This desquamation of the 
superficial cells is often a 
very prominent feature of 
the disease and may render 
the diagnosis extremely dif- 
ficult. These cells, as they 
are rapidly cast off, accumu- 
late in the canal and, owing 
to its contracted calibre, are 
with great difficulty cleared away so as to permit a view of 
the small portion of the drum membrane not hidden by the 
swollen canal wall. The swelling is intensely painful to ma- 
nipulation with the probe ; pressure in front of the tragus or 
efforts at crowding the canal upward or forward are attended 
with severe pain. There may be considerable oedema over the 
post-auricular region, and the auricle may be displaced out- 
ward and forward from the side of the head more or less 
prominently. Palpation along the anterior border of the 
sterno-mastoid muscle reveals considerable infiltration of the 
lymphatic glands. When this condition occurs with oedema 
over the mastoid the differential diagnosis between diffuse ex- 
ternal otitis and perforation at the tip of the mastoid is possi- 
ble only by speculum examination alone. It is exceedingly 




Fig. 88. — Acute diffuse external otitis, in- 
volving postero - superior canal wall. 
(Natural size.) 



258 DIFFUSE EXTERNAL OTITIS. 

important in these cases to prolong the speculum examination 
sufficiently to determine the coexistence of any inflammatory 
condition within the tympanum. This is particularly true in 
the case of children, since an acute purulent otitis media, if 
severe, may be accompanied by a diffuse inflammation in the 
external meatus, and the early recognition of the true nature 
of the disease is a matter of great importance. The surgeon 
should therefore obtain a view of the drum membrane, al- 
though this may require considerable time and inflict a certain 
amount of suffering upon the patient. Where the parts are 
very much swollen and the view is obstructed by desquamated 
epithelium, the persistent use of small cotton-tipped probes 
will enable us to clear this away, and to reduce the swelling 
by pressure sufficiently to permit an inspection of the drum 
membrane, or at least of a portion of it. If this is normal in 
color we are warranted in the assumption that the disease is 
confined to the canal alone. 

Prognosis. — The progress of the affection will depend 
largely upon the causation. If it is idiopathic the prognosis 
is good ; if dependent upon traumatism, either mechanical, 
chemical, or thermal, the outcome will depend upon the se- 
verity of the injury inflicted. As complicating an acute or 
chronic process within the middle ear the severity of the lesion 
within the tympanum furnishes an index of the probable out- 
come of the case. When arising from a previous chronic in- 
flammation of the canal without any special exciting cause, the 
disease is usually mild in character. The degree of constitu- 
tional disturbance does not indicate the probable severity of 
the attack, as in the early stages ; the general symptoms are 
usually very well marked even in mild cases. 

Treatment. — The first efforts should be directed toward 
relieving the severe pain which the patient suffers, and the 
attempt should be made possible to abort the process before 
the stage of pus formation is reached. For the relief of pain, 
both local and general measures are indicated. A sufficiently 
large dose of morphine or some preparation of opium should 
be administered, either by the mouth or, if the severity of the 
attack demands it, by the hypodermic method. The patient 
should be confined to bed and kept as quiet as possible ; it is 
also well to obtain a certain amount of revulsive action by 
the administration of a saline cathartic. If seen very early, 
we may resort to local bloodletting, removing, by means of 



TREATMENT. 



259 



the artificial leech, not less than two ounces of blood. The 
site from which this is removed will depend somewhat upon 
the region in which the process seems to be most severe, but 
as a rule in the diffuse form of inflammation the best results 
-are obtained by the abstraction of blood from the mastoid 
region ; here preference should be given to the artificial 
leach rather than to the natural. Immediately after the ab- 
straction of blood the Leiter coil should be applied to the 
mastoid region, or the aural ice bag may be used if this is 
more agreeable to the patient. If for any reason local de- 
pletion seems inadvisable, we may proceed at once to apply 
the ice coil or ice bag. In addition to this, considerable re- 
lief is often obtained by frequently irrigating the canal by 
means of the ear syringe, or, better, by employing the foun- 
tain syringe. A weak antiseptic solution, as of bichloride of 
mercury, one to eight thousand, or a saturated aqueous solu- 
tion of boric acid, is to be used for this purpose. The warm 
fluid should be allowed to flow into the meatus for a period 
of from five to fifteen minutes, according to the relief which 
it affords. In this manner the parts are cleansed and the 
analgesic effect of the warm douche obtained. It is not neces- 
sary to remove the ice coil from the mastoid region in order 
to carry out this measure, and although the two would seem 
to be apparently opposite in action, the effect obtained is 
often very satisfactory. This plan of treatment should not 
be persisted in for more than twenty-four hours, at the end 
of which time, if the symptoms are not so much relieved that 
the patient is able to rest without the use of an opiate, and 
complains of but little or no spontaneous pain, more active 
measures are demanded. At this period no treatment, to my 
mind, is so efficacious as a deep free incision in the canal, 
relieving at the same time the tension of the parts and effect- 
ing local depletion. In order to be efficacious, the incision 
should be deep and of considerable length. The site of elec- 
tion is usually the posterior or postero-superior wall of the 
canal. Under illumination by means of the head mirror, a 
sharp stout knife, such as is shown in Fig. 87, should be carried 
through the swollen canal wall, close to the drum membrane, 
until the point of the instrument is felt to impinge upon the 
bone. The incision is then extended directly outward for 
from one half to three fourths of an inch, dividing all the over- 
lying structures, the point of the knife being kept in contact 



2 6o DIFFUSE EXTERNAL OTITIS. 

with the bone throughout the entire length of the incision. 
When possible, the operation should be performed un- 
der nitrous oxide anaesthesia. The relief is almost imme- 
diate, and is complete usually at the end of twelve hours. 
Hartmann * strongly advises against incision in the acute 
form of diffuse external otitis, asserting that improvement 
never follows the procedure, while frequently the condition 
is much aggravated. Certainly this has not been my experi- 
ence, although I hesitate to differ with so high an authority. 
The only possibility of this measure inflicting injury would be,, 
it seems to me, in cases where the field of operation had not. 
been properly cleansed. If the canal is freely irrigated before 
the incision is made I can see no reason why the result should 
be anything but satisfactory. After the operation the ear is. 
to be syringed every two to four hours with a mild antiseptic 
solution. This irrigation is to be continued until the local 
condition becomes normal, the frequency being diminished 
gradually. Complete resolution with restoration of the nor- 
mal calibre of the canal is frequently rather slow, and may 
not occur for several weeks. During this period the canal 
is apt to be the seat of a desquamative inflammation, the epi- 
thelium being rapidly thrown off, while at the same time a 
certain amount of serous transudation takes place, causing a 
thin turbid discharge from the canal. In this condition the 
meatus offers a favorable site for the development of asper- 
gillus, and our efforts at cleansing the parts should not cease 
until the discharge has entirely disappeared. For the first 
few days the most relief will be obtained by the use of one 
of the antiseptic solutions, the canal being cleansed from two 
to four times daily, according to the amount of discharge. 
After the discharge has ceased the use of any fluid in the 
canal rather prolongs the process, and the parts will more 
quickly return to their normal condition if the walls of the 
meatus are dusted lightly with some antiseptic or astringent 
powder, such as finely divided boric acid, oxide of zinc, der- 
matol, bismuth subnitrate, or any similar substance. If it is. 
necessary to leave the treatment largely to the hands of the 
patient, alcoholic solutions may be used in place of powders. 
Of these, a four- or eight-per-cent solution of boric acid in 
dilute alcohol is probably the most efficacious. If the dis- 
charge continues, after the use of the powders and upon 

* Krankheiten des Ohres, Berlin, 1889, p. 99. 



CROUPOUS AND DIPHTHERITIC EXTERNAL OTITIS. 261 

thoroughly drying- the ear by means of the cotton pledget, 
we find that the cutaneous surface is reddened and moist, a 
stimulating application, such as a solution of nitrate of silver, 
lightly brushed over the canal will frequently cause the walls 
to return rapidly to their normal condition. In making these 
applications a comparatively mild solution (about ten grains 
to the ounce) should be used at first, the strength being grad- 
ually increased according to the indications. These applica- 
tions may at first be made daily, and afterward at longer inter- 
vals. If the disease is not seen in its early stages and, in spite 
of our efforts, there is considerable destruction of tissue, the 
affection may result in a perichondritis of the auricle, with 
partial necrosis of the cartilaginous framework. The treat- 
ment of this affection has already been considered. If our 
efforts to limit the pathological process to the soft parts are 
unsuccessful and there is an involvement of the underlying 
osseous structures, the case is to be dealt with according to 
the rules laid down for the management of acute inflamma- 
tion of the mastoid process. 

In every case of acute inflammation of the external 
meatus it is to be remembered that so long as we confine the 
process to the canal walls we have an affection, the manage- 
ment of which is comparatively simple. The danger is that 
it may either extend to the bony or cartilaginous structures, 
on one hand, or may involve the tympanic cavity secondarily, 
in which case we have to deal with a suppurative process 
within the middle ear. Moreover, where extension to the 
tympanum occurs, it is the upper part of the cavity which is 
involved. As this portion of the tympanum is richly sup- 
plied with cellular tissue, the complication constitutes a men- 
ace to life. 

Croupous and Diphtheritic External Otitis. 

The diseases included under the above heading constitute, 
in reality, but minor subdivisions of diffuse external otitis. 
Since the epidermis covering the meatus differs in no respect 
from that covering other portions of the bodv, we have no 
reason to presume that it should be exempt from the above 
special types of inflammation. Under favorable conditions 
the germ either of croupous or of diphtheritic inflammation 
may find lodgment within the meatus and produce there its 
characteristic exudation. The croupous form is less com- 



262 DIFFUSE EXTERNAL OTITIS. 

monly observed than the diphtheritic. Like a croupous in- 
flammation in other portions of the body, it is characterized 
by a white, thick, velvety deposit on the surface of the mem- 
brane involved, consisting of coagulated fibrin containing 
within its meshes white blood corpuscles. This deposit lies 
immediately upon the surface, and can be detached from the 
underlying structures without the rupture of blood vessels. 
It is probable that certain conditions of the general health 
render the patient particularly prone to this form of inflam- 
mation. The condition known as hyperinosis, or an increase 
in the fibrin elements in the blood, is undoubtedly the chief 
predisposing factor. Given this general condition, and a 
simple inflammation of the epidermis lining the meatus, the 
lodgment of the specific germ of croupous inflammation will 
ordinarily be followed by a change from the simple type to 
the croupous form. 

The diphtheritic form, on the contrary, is most frequently 
observed as a complication of otitis media, dependent upon 
either a diphtheritic inflammation of the fauces or the angina 
of scarlatina, although it occasionally occurs as a primary 
affection. When occurring as a complicating lesion, the 
source of infection is usually the middle ear ; a purulent in- 
flammation here, with subsequent rupture of the membrana 
tympani, being followed by a purulent discharge which con- 
tains the specific diphtheritic germ. Such an otitis media is 
accompanied by a diffuse external otitis in most cases. The 
external meatus is therefore in a condition favorable to the 
lodgment and development of the diphtheritic germ. 

The physical examination reveals, in the early stages, the 
walls of the meatus covered with a white deposit, or, if ob- 
served only in the period of necrosis, with a grayish-white 
membrane, which is firmly attached to the underlying skin, 
and can be removed only by the use of considerable force, the 
removal being attended with the rupture of blood vessels. 
When spontaneous exfoliation has taken place, the exposed 
areas show a loss not only of the superficial epithelium, but 
also of the deeper layers, the condition being one of true 
ulceration. The fibrous structures of the cutis are also affect- 
ed, becoming swollen and encroaching markedly upon the 
lumen of the passage. The condition, whether of primary or 
secondary origin, presents the same picture, and its recogni- 
tion is not difficult. It might be confounded with croupous 



TREATMENT. 263 

inflammation, but if we bear in mind that a croupous deposit 
separates from the underlying parts without haemorrhage, the 
mistake need not be made. The severe type of desquamative 
inflammation of the canal, either occurring primarily or de- 
pendent upon an otitis media purulenta, may also lead to 
error. Here, however, the deposit is not membranous, but 
consists simply of necrotic epithelial cells superimposed upon 
each other. There is no destruction of tissue, and upon re- 
moval no ulceration remains. In the same way an aspergillus 
within the canal may be mistaken for a diphtheritic inflam- 
mation, but the microscope will easily reveal the true charac- 
ter of the disease. The history of the case will also enable a 
differentiation to be made between the various conditions. 

The presence of a croupous or diphtheritic deposit in the 
external canal, when occurring as a secondary disease, is usu- 
ally no serious matter, since the surface presented for the 
absorption of the toxine of the diphtheria bacillus is one 
through which this takes place very slowly ordinarily. In 
cases where the diphtheritic deposit in the canal is but a sec- 
ondary feature of the general infection the outcome depends 
upon the severity of the original disease without reference to 
the local manifestation in the auditory meatus. Occasionally 
such deposits occur primarily, the germ gaining access to the 
external canal in some unknown way, and taking root there 
upon an abraded surface which has resulted from a traumatic 
or other cause. In such instances only very slight constitu- 
tional symptoms are apt to be present, and the danger to be 
feared most is that the inflammation of the external canal may 
extend inward and involve the tympanum, the mucous lining 
of which would permit general infection more easily than 
would cutaneous lining of the canal. Croupous deposits are 
of trivial importance aside from the local pain which is pres- 
ent, and this is no more severe than in simple diffuse inflam- 
mation. 

Treatment. — The treatment of the local condition consists 
in the thorough and frequent cleansing of the surface involved 
to prevent the membrane from spreading bv contiguitv of 
structure, thus increasing the extent of the surface through 
which the poison may enter the circulation. A diphtheritic 
membrane in any situation will be exfoliated spontaneously at 
the end of from three to eight days. If removed bv violence 
before this time, blood vessels are opened, and the raw surface 



204 DIFFUSE EXTERNAL OTITIS. 

becomes covered very quickly by a new deposit, while the 
laceration of the vessels rather favors the absorption of the 
poison. It is wise, therefore, to confine our efforts to keeping 
the parts thoroughly cleansed, in this manner diminishing the 
activity of the germ, taking care that our efforts are not so 
vigorous as to excite any inflammatory reaction on the sur- 
rounding parts. To effect a thorough cleansing of the canal 
we may resort to the use of the ear syringe, or, perhaps bet- 
ter, the fountain syringe, employing a solution of lime water, 
which is allowed to flow into the canal for from five to ten 
minutes. In this way portions of the deposit already necrotic 
are removed, and a certain amount of solvent action is exerted 
upon the transudation which is still firmly attached to the 
parts beneath. Antiseptic solutions may be used here, the 
strength of the solution being somewhat greater than that 
employed for ordinary cleansing purposes. In this way the 
deposit is rendered inert, while at the same time, by its pres- 
ence, it protects the surface to which it is attached, and when 
it exfoliates spontaneously the denuded surfaces are protected 
by the presence of granulation tissue, which offers a barrier 
to local infection. 

In addition to irrigation, certain medicinal preparations 
may be applied to the deposit by means of the cotton applica- 
tor ; of these, I think the solution of ferric sulphate in the full 
strength is by far the most efficacious. This causes a rapid 
necrosis of the superficial layers of the pseudo membrane, 
while at the same time it exerts no irritating action, even if 
it touches parts which have not yet become affected. This 
local necrosis inhibits or stops completely the growth of 
the germ, putting an end both to its toxic effect upon the 
general system and to its further local propagation. A croup- 
ous exudate may be managed in exactly the same manner, its 
separation being more easily effected than one of a true diph- 
theritic character. In this form, after the iron solution has been 
applied, it is often possible to remove a considerable portion 
of the deposit by means of the forceps without inflicting any 
injury upon the cutaneous lining of the canal. The adminis- 
tration of constitutional remedies will be governed by the 
same rules which apply to similar deposits located in the 
fauces. Remembering that a croupous exudation has for its 
predisposing cause a certain blood condition, it is wise to ad- 
minister the tincture of the chloride of iron in large doses, 



HEMORRHAGIC EXTERNAL OTITIS. 265 

with the hope of cutting- short the attack. In the same man- 
ner a diphtheritic membrane appearing in the meatus, if ac- 
companied by the characteristic constitutional symptoms of 
septic infection, demands the free use of stimulants and such 
drugs as may be believed to mitigate the action of the poison. 
The various local complications do not differ from those al- 
ready mentioned under acute external otitis. 

HEMORRHAGIC EXTERNAL OTITIS. 

Under this term Politzer* has described a disease of the 
external auditory meatus characterized by the presence of 
vesicles upon the walls of the canal. The inferior and anterior 
walls are usually the seat of the manifestation, although the 
other walls are occasionally affected. These vesicles are filled 
with a bloody fluid, and if allowed to remain, disappear spon- 
taneously at the end of a few days, their site being marked by 
an excoriated area. 

The disease may occur either as a primary affection or as 
a complication of an acute inflammatory process within the 
tympanum. The constitutional symptoms are very well 
marked, and consist of intense local pain, which frequently 
assumes a neuralgic character, spreading over the entire side 
of the head ; the temperature is elevated to from 99 to 102 , 
and there is a marked prostration ; occasionally delirium is 
present. The occurrence of this condition in the severe forms 
of tympanic inflammation which complicate constitutional dis- 
eases of the infectious type, particularly epidemic influenza, 
seems to show that the condition is indicative rather of a 
marked general infection than of any distinct local patho- 
logical process. In cases where we meet with this form of 
external otitis as an idiopathic disease, I am more inclined to 
consider it as either a tropho-neurosis similar in many re- 
spects to herpes, or, if the deeper layers of the canal are in- 
volved, as an accidental complication of a simple diffuse otitis. 
The latter view is that taken by Gruber,f and this seems to be 
entirely tenable. It is not improbable that the extravasation of 
blood cuts short the inflammatory process in the same manner 
as local depletion by artificial means, when the above measure 
is employed therapeutically in inflammation of the canal. 



* Lehrb. der Ohrenheilk., Stuttgart, 1893, p. 154. 
+ Lehrb. der Ohrenheilk., Vienna, iSSS, p. 280. 



266 • DIFFUSE EXTERNAL OTITIS. 

Treatment. — The primary indication for treatment is to 
relieve the constitutional symptoms, the local condition being 
unimportant and requiring but little attention. The intense 
suffering must be relieved by the administration of free doses 
of morphine hypodermically. When the neurotic symptoms 
are well marked the administration of bromide of sodium 
in full doses will do much to render the patient more com- 
fortable. Complete rest should be insisted upon. The diet 
of the patient should consist mostly of fluids for the first 
twenty-four or forty-eight hours. The disturbance of the 
nervous system frequently brings about severe constipation, 
which in turn increases the severity of the local pain. It is 
well, therefore, early in the affection to administer calomel in 
small repeated doses until the effect upon the intestinal canal 
is obtained, its action being aided, if necessary, by a saline 
cathartic. Locally very little need be done, the condition 
within the canal being kept under observation in order that 
any tendency toward inflammation of the middle ear may be 
readily recognized and proper measures instituted to check it. 
If the vesicles are of considerable size they may be opened 
with a delicate knife, the walls of the vesicles being preserved 
as much as possible to protect the denuded areas within the 
canal. In case of spontaneous rupture the site of the vesicles 
may be lightly dusted with zinc oxide, lycopodium, bismuth, 
or any bland powder which will protect them until they are 
covered by normal epithelium. Occasionally these vesicles 
are located upon the tympanic membrane, in which event the 
pain is of unusual severity and the constitutional symptoms 
are correspondingly increased. In such cases it is wise to 
open the vesicles as soon as they appear, since almost imme- 
diate relief follows. Care should be taken that the canal is 
in a thoroughly aseptic condition before the operation, and 
the operator should guard against introducing the knife too 
deeply for fear of wounding the deeper layers of the drum 
membrane, and of opening into the tympanic cavity. The 
local tenderness renders manipulation difficult, and, unless 
the head is firmlv held by an assistant, either of the above 
accidents is liable to occur. The sensitiveness of the region 
may be reduced somewhat by filling the canal with a ten-per- 
cent aqueous solution of cocaine about twenty minutes before 
the operation is to be performed. This solution must, of 
course, have been previously sterilized by boiling. 



CHAPTER XIII. 

IMPACTED CERUMEN. 

While constituting a condition which differs in no respect 
from that present when any foreign body is present in the 
meatus, this disease is of such common occurrence that it 
seems wise to consider it under a separate chapter. 

iEtiology. — The causes which lead to this condition de- 
pend either upon the production of an increased amount of 
the normal secretion of the ceruminous glands, or upon an 
interference with its regular discharge from the canal. In 
health cerumen is continually formed by the glands found in 
the meatus, and is discharged from the canal constantly, but 
in such small quantities that its presence is unnoticed. Any 
obstructive condition interfering with this process leads to 
an accumulation of the secretion within the meatus, and if it 
exists for a long period of time a considerable mass will ac- 
cumulate, varying in size and density according to the activity 
of the secretory process and the length of time that the ob- 
struction has existed. The conveyance of the product along 
the meatus is effected principally by the action of the jaws 
during mastication and speaking. With every motion at the 
intermaxillary articulation the anterior and inferior walls of 
the canal are moved, on account of the intimate relation be- 
tween the tragus and the capsular ligament of the articulation. 
This motion, when the canal is of normal size and shape, acts 
in such a manner that any foreign body within the fibrous 
meatus is moved constantly toward its orifice. If the canal 
presents certains anomalies in curvature or if the orifice is 
very narrow, the force may have exactly the reverse effect, 
and any body lying within the passage may be carried in the 
opposite direction — that is, deeper and deeper into the canal 
toward the drum membrane. If a small mass of cerumen 
collects in the canal its mere presence causes an increased 
amount of secretion from the glands lying in the immediate 

(267) 



268 IMPACTED CERUMEN. 

vicinity, while, at the same time, it acts as an obstruction to 
the outward passage of the product of the glands lying deeper 
within the channel. 

Although the causes stated are those most frequently 
operative in the production of the impaction of cerumen, it 
must be remembered that the secretory power of any gland 
may be modified by interference with its nerve supply. Under 
certain conditions we are warranted in considering that the 
disease is of a tropho-neurotic character. It is certain that 
the opposite condition, or one in which the cerumen is dimin- 
ished in quantity is frequently encountered in proliferous in- 
flammation of the middle ear. Proliferous otitis media fre- 
quently depends upon some perversion of the trophic nerve 
supply, and we are warranted in assuming that an increased 
amount of cerumen may occasionally occur from tropho- 
neurotic causes. 

Pathology. — Upon removal of these masses from the mea- 
tus they are found to contain not only the oily substance which 
is normally secreted by the parts, but also certain vegetable 
spores, the presence of which is purely accidental. The mass 
is occasionally covered by desquamated epithelium, while not 
infrequently we find in the centre a foreign body which has 
found its way into the meatus at some time and has formed 
a nucleus, about which the normal secretion has collected. 

This description applies to the simple cases of impacted 
cerumen. When, however, the masses attain considerable 
size the pathological process is more complex, and there is 
in addition a chronic desquamative inflammation of the deep 
canal dependent upon the presence of the foreign body. 
For the same reason the glands are probably stimulated to 
increased activity. As long as the mass consists of cerumen 
only, no considerable changes are wrought upon the bony 
walls of the passage ; when added to this, however, an inflam- 
mation of the desquamative type is set up by the presence of 
this foreign body, the osseous walls may be partially de- 
stroyed or the deep part of the canal may be enormously 
dilated. This is especially prone to take place in the region 
of the posterior wall, and the pneumatic spaces of the mastoid 
are obliterated. In some instances a chronic osteitis is devel- 
oped by the pressure, and the mastoid cells not only disap- 
pear, but the entire process becomes sclerosed and of ivory- 
like hardness. The membrana tympani may be perforated by 



SYMPTOMATOLOGY. 269 

the pressure, and the removal of the mass may then reveal 
extensive pathological changes within the middle ear. 

Symptomatology. — The symptoms dependent upon the 
condition vary with the size of the mass, with its location, and 
with the amount of secondary inflammation which its presence 
has excited. The lumen of the meatus may be encroached 
upon to a considerable extent without any noticeable impair-, 
ment of the auditory function, or without the appearance of 
any subjective symptoms, such as tinnitus, autophony, or a 
feeling as if the canal were stopped. On the other hand, a 
very small mass may be so situated as to give rise to promi- 
nent symptoms. If it is in such a position that the membrana 
tympani is pressed upon, the subjective symptoms are apt to 
occur early, and the function of the organ may be appreci- 
ably interfered with, even though the mass be small. Again, 
a large collection of cerumen may lie in the cartilaginous 
meatus and almost completely occlude its lumen without 
causing any symptoms referable to the ear. Frequently the 
first intimation of any trouble will be the occurrence of sud- 
den impairment of hearing following a plunge bath, when, 
on coming out of the water, the ear feels " stuffy " and full. 
These sensations are at first attributed to the presence of 
water in the canal. The efforts of the patient to remove 
this failing to relieve the discomfort, he seeks advice, and an 
examination reveals the presence of a mass which, from its 
size, must have been in the canal for a considerable period 
of time. The sudden access of the symptoms is due to the 
displacement of the plug by the water which has entered 
the meatus, causing it to assume a position where it com- 
pletely obstructs the passage. In other cases the patient be- 
comes conscious that the power of hearing is gradually but 
constantly diminishing ; coexistent with this impairment of 
function subjective noises make their appearance, at first 
causing but little annoyance, but subsequently becoming so 
loud and persistent as to cause him to seek relief. Where 
the occlusion is marked the patient often complains of au- 
tophony, hearing his own voice as if it came from within 
the head. This symptom is particularly marked where the 
affection is confined to one side. Occasionally the mass may 
give rise to a severe neuralgia, not confined to the ear alone. 
but spreading over the temporal and supra-orbital regions, 
and sometimes involving the entire trigeminal distribution 
19 



270 IMPACTED CERUMEN. 

Sometimes this affection of the sensory nerves produces a 
feeling not so much of pain as of numbness, involving the 
aural region or the entire side of the face. 

One of the most common reflex disturbances is cough. 
So common is this that examination of the ear is essential in 
the investigation of every case when complaint is made of 
this symptom alone. This cough is spasmodic in character,, 
and from its severity may induce so much congestion of 
the larynx as to mislead the physician into believing that 
the laryngeal condition is the cause rather than the effect of 
the symptom. 

Not only is the auditory function perverted or impaired, 
but also the mental condition of the patient may be disturbed. 
The patient graduallv finds that he is unable to concentrate 
his thoughts upon any one particular subject, and that all 
mental processes are slow. The condition may become so 
marked as entirely to unfit him for any occupation requiring 
the exercise of his mental faculties. This disturbance is de- 
pendent entirely upon reflex action, and not upon the impair- 
ment of the hearing. Attention is particularly drawn to it 
from the fact that parents are often inclined to consider chil- 
dren inattentive when they are really suffering from a reflex 
disturbance dependent upon some pathological process within 
the ear. In these cases, unless attention is particularly directed 
to this organ by an impairment of hearing, serious errors are 
liable to occur. 

Under this same head we must remember that interfer- 
ence with the function of the ear of the opposite side may 
result from the presence of a foreign body within the meatus. 
While this phenomenon is rarely prominent, every one who 
has carefully tested the hearing in both ears, in cases where 
the canal of one side has been occluded by a foreign body, 
must have noticed that we seldom find the ear on the unaf- 
fected side normal, although the patient may be conscious 
of no impairment, and if questioned will usually reply that 
the other ear is perfectly sound. When we remember the in- 
fluence which a sounding body held before one ear has upon 
the sensitiveness of the organ of the opposite side, it is not 
strange that an occlusion of the external canal upon one side 
may seriously interfere with the hearing power of the oppo- 
site ear. 

So far we have considered simply reflex disturbances of a 



DIAGNOSIS. 271 

sensory nature ; many cases have been reported, however, in 
which epileptiform seizures have resulted from the presence 
either of impacted cerumen or of some other foreign body 
within the external auditory meatus, the attacks being entirely 
relieved upon its removal. Dizziness may occur from the 
direct pressure of the impacted cerumen upon the drum 
membrane, by which the attached ossicular chain is crowded 
inward, increasing labyrinthine pressure ; it may result also 
from reflex disturbances due to circulatory changes within 
the semicircular canals or the intracranial centres. 

When the impaction takes place in an ear which has pre- 
viously been the seat of purulent inflammation, in addition to 
the symptoms already described, serious consequences may 
result from the obstruction to the free outflow of discharge. 
This is particularly apt to occur in cases of chronic purulent 
otitis media of long duration, where the discharge is small in 
quantity as a rule, but may be suddenly increased in amount 
from exposure to cold or some other cause. In these cases, 
the scant discharge, mixed with the normal cerumen, dries in 
the canal and forms crusts, sometimes of almost stony hard- 
ness, which prevent the exit of any fluid which may be 
formed within the middle ear during an acute inflammation 
of the parts. It is possible here for the pent-up secretion to 
find entrance into the cranial cavity, and cause death by in- 
volving the intracranial structures. 

Diagnosis. — It is impossible to make a diagnosis upon 
rational symptoms alone, but objective examination at once 
reveals the condition. Upon inspecting the parts, occlusion 
of the canal is at once evident, and the determination of the 
exact nature of the mass before removal is of no importance. 
Attention, however, should be given to one point in the ex- 
amination of these cases : it is the presence on the postero- 
superior wall of the canal of a mass consisting apparently of 
cerumen, which extends along this aspect of the meatus in- 
ward over the drum membrane, entirely or partially covering 
it. This appearance is almost always indicative of a pre- 
ceding suppurative process within the tympanum, the foreign 
body being really inspissated secretion, mixed with a certain 
amount of normal cerumen. Before removing this, the patient 
should always be warned that the ear may discharge after 
the mass has been removed. The subsequent otorrhcea does 
not depend upon the removal of the mass, but upon a pre- 



\J2 



IMPACTED CERUMEN. 




Fig. 89. — Crust on supero-posterior 
wall, covering a perforation in 
the membrana tympani. (Natural 
size.) 



viously existing intratympanic suppuration. If not warned 
beforehand the patient may scarcely understand this. Where 
the meatus is entirely occluded, and a view of the deeper 
parts is impossible, this condition may be present, and it is 

often wise for the surgeon to 
protect himself even here, al- 
though it is not of as great im- 
portance as when the mass oc- 
cupies the situation above de- 
scribed. 

Prognosis. — The presence of 
a mass of cerumen in the exter- 
nal auditory meatus does not of 
itself constitute a menace to life, 
nor does it prevent a complete 
restoration of the auditory func- 
tion after the removal of the for- 
eign body. The serious conse- 
quences which occasionally fol- 
low the presence of these masses 
is due to secondary pathologi- 
cal changes which they excite, 
either by causing hyperemia and subsequently inflamma- 
tion, as the result of their pressure, or by setting up an in- 
flammatory process of desquamative type in the external 
auditory meatus, with a resultant absorption of the surround- 
ing bony walls or a perforation of the membrana tympani. 
When the affected ear is the seat of a chronic purulent otitis 
media, the presence of any foreign matter within the canal 
which may prevent the free discharge of pus from the middle 
ear renders the patient liable to all the serious consequences 
which may follow pus retention in any other part of the 
body. It seems curious that a mass of cerumen can offer 
sufficient resistance to pent-up secretions to cause them to 
seek an exit through the cells of the mastoid process, or to 
discharge into the cranial cavity, rather than to force their 
way past the obstruction in the external auditory meatus. 
The fact, however, remains that a mass of cerumen, lodged in 
the meatus for a considerable time, will obstruct this passage 
so completely that no discharge can escape. The osseous 
walls of the mastoid cells yield more easily to the pressure of 
pent-up secretions than does this mass of fatty matter. Again, 



PROGNOSIS. 



273 



in these cases the mere presence of this collection within the 
meatus excites a certain amount of chronic inflammation of 
the epidermis lining- the canal, this inflammation being usu- 
ally of the desquamative type. The slight amount of dis- 
charge from the tympanic cavity mixing with these desqua- 
mated epithelial cells forms a mass which is exceedingly firm, 
and which, increasing gradually in size, is capable of causing 
absorption of the osseous walls. The extent to which this 
may progress is unlimited, and even the cranial cavity may 
be invaded and a purulent infection of its contents may re- 
sult. In cases where the tympanic membrane remains intact, 
the pressure of the mass may force this structure inward 
against the bony tympanic wall, and by pressure cause an 
atrophy of the fibrous layer of the membrane. At the same 
time the desquamative inflammation excited by the plug of 
cerumen involves the superficial layer of the drum membrane 
as well as the canal walls. The epithelial cells which have 
been cast off may adhere so firmly to the atrophic membrana 
tympani that upon removal of the foreign body this delicate 
septum may be ruptured in spite of the greatest care. Even 
if the membrane is ruptured, complete restoration of func- 
tion may take place, although the accident adds a certain 
amount of gravity to the condition. It is always well, there- 
fore, for the surgeon to protect himself by giving a guarded 
prognosis in any case of ceruminous impaction in the canal, 
in which the mass seems to be of considerable firmness, and 
when there is evidence that it has existed for a long time. 
The effect upon the opposite ear should always be borne in 
mind, and a careful test of the hearing power upon both sides 
should be made. before and after removal. If the accumula- 
tion is recent, complete restoration of the normal hearing 
power may be confidently expected. If, however, we have 
reason to believe that the canal has been obstructed for sev- 
eral years, it is probable that the hearing will not be perfect 
even after the foreign body has been removed. Moreover, 
since complete occlusion of the meatus makes it impossible 
for the observer to inspect the condition of the deeper parts, 
an absolute opinion should be given only after the obstruction 
has been thoroughly cleared away and the fundus of the canal 
exposed to view. 

These masses within the meatus exert considerable pres- 
sure upon the surrounding walls, and their sudden removal 



274 



IMPACTED CERUMEN. 



often causes a transitory hyperaemia of the parts, which par- 
ticularly predisposes to the development of a circumscribed 
inflammation, and the appearance of a furuncle following 
the operation is by no means of rare occurrence. In other 
instances, this sudden increase in blood pressure causes a 
rupture of the superficial vessels, developing a blood bleb 
upon the walls of the meatus, usually upon the inferior wall, 
close to the membrana. This may attain such a size as to 
obstruct the canal considerably, while its color so nearly re- 
sembles that of the ceruminous deposit as to be mistaken for 
it. The operator is liable to inflict considerable violence upon 
the patient before the mistake is discovered, unless he bears 
the possibility of this occurrence in mind. 

In one instance coming under the observation of the 
author this sudden removal of support to the blood vessels 
was followed by a serous transudation into the tympanum. The 
amount of fluid effused was so great as to cause intense pain 
from pressure upon the membrana tympani. A free incision 
through the membrana gave exit to the fluid, and was fol- 
lowed instantly by relief. 

Treatment. — The first indication in a case of this char- 
acter is to remove the mass, and it can not be too strongly 
insisted upon that when an effort to remove such an accumu- 
lation from the external auditory canal has been instituted, it 
should not be discontinued until the canal has been completely 
cleared. 

An exceedingly pernicious habit is practiced, not only by 
physicians without special training but by many otologists 
as well, of ordering these patients to instil a few drops of an 
alkaline solution into the ear at regular intervals for the pur- 
pose of softening the mass of cerumen, to render removal 
more easy at a subsequent period. As we know nothing of 
the conditions of the deeper parts, it seems strange that this 
method of procedure has ever been countenanced. The 
symptoms caused by the obstruction may be so indefinite 
that almost any condition may coexist, and to allow the 
patient to pass from observation without determining defi- 
nitely the presence of any coexisting pathological condition 
within the tympanum is certainly unwise. Another reason 
for condemning this plan lies in the fact that these masses 
may consist largely of dry epithelial cells, and the absorption 
of moisture will considerablv increase their volume. In this 



TREATMENT— SYRINGING. 



275 



manner great pressure will be exerted upon the walls of the 
meatus, causing" intense suffering to the patient, and frequently 
leading to a circumscribed external otitis. 

The cardinal rule, therefore, should always be to remove 
the collection at the first sitting. The instrument which is 
best adapted for this purpose is the ordinary ear syringe (Fig. 
82). In a large majority of cases thoroughly syringing the ear 
will remove such a collection in a few moments. The solution 
to be used is a matter of considerable importance, for, as the 
condition of the deeper parts is unknown, the fluid should be 
of such a character that its entrance into the tympanic cavity, 
through the accidental rupture of the drum membrane or 
through a previously existing perforation, would be followed 
by no serious consequences. The syringe, therefore, must be 
perfectly aseptic, and the solution used should possess anti- 
septic properties. A solution of the bichloride of mercury — 
1 to 5,000 or 1 to 8,000 — is the one which I prefer. The fluid 
should be used at a lukewarm temperature, the sensations of 
the patient being the guide to the exact temperature to be 
employed. Since the removal of the obstruction in this man- 
ner depends upon the passage of a stream of water between 
it and the canal wall, and the gradual crowding outward of 
the mass by this current, the stream should be directed 
where the greatest space exists between the foreign body and 
the canal wall. Naturally, if the current impinges directly 
upon the centre of the obstruction, this will be driven inward 
rather than outward. If, on inspection, we find that the in- 
spissated secretion is firmly attached on all sides to the walls 
of the passage, it is frequently advisable to begin the process 
by removing a small portion of the mass close to the canal 
wall with a blunt curette, in order that the stream may be 
able to pass the obstruction. The force to be used in the 
procedure is best guided by the sensations of the patient ; the 
syringing should never be painful, although in certain in- 
stances the mere entrance of the stream of water will cause 
considerable dizziness. It is well to begin by using very little 
force, gradually increasing it as may be necessary. If we 
were certain that the drum membrane were in its normal con- 
dition it would be almost impossible to rupture it by the use 
of the ordinary ear syringe. As it may be atrophic, however, 
care should be taken that no undue violence is employed in 
our efforts at removal. Where inspection reveals the canal 



276 



IMPACTED CERUMEN. 



completely stopped by the mass, and the use of the curette in 
the manner already described seems inadvisable, the plan 
usually followed is to direct the syringe so that the stream of 
water will impinge first upon the superior wall of the canal, 
next the posterior, then the inferior, and last upon the ante- 
rior wall. If the circumference of the canal is followed in this 
order, the instances will be rare in which the plug will not 
be rapidly displaced, the water at some particular point gain- 
ing entrance between the wall and the obstructing body, and 
rapidly forcing it outward with each successive discharge of 
the syringe. We occasionally meet with cases which resist 
all efforts at removal in this manner ; in such an event the 
blunt curette must be used, and the collection removed piece- 
meal. Here it should be borne in mind that the upper and 
posterior portion of the drum membrane is nearer the opera- 
tor than the lower and anterior portion; it is unsafe, /there- 
fore, to undermine the deposit by following the anterior wall 
of the canal and then attempt its removal by crowding the 
curette upward against the remaining portion, endeavoring 
to displace it by traction outward. If the drum membrane is 
sunken, pressure will be brought directly against this struc- 
ture and much suffering will certainly follow, and in many 
instances it will be ruptured. It is wiser, therefore, to follow 

the posterior wall of the 
canal inward, effecting 
removal of the mass by 
pressing the curette down- 
ward and forward toward 
the anterior wall, at the 
same time employing trac- 
tion outward, removing 
in this way so much of the 
mass as lies between the 
curette and the opposite 
canal wall. After the 
drum membrane has been 
once brought into view, 
the remaining fragments 
may be displaced either 
by the syringe or by the use of the curette, following any 
particular manipulation that may seem adapted to the de- 
mands of the individual case ; but until this structure is seen. 




Fig. 90. — Method of removing cerumen with 
the curette. (Natural size.) 



TREATMENT— USE OF THE CURETTE. 277 

the plan above laid down is the one which should be followed. 
Where the canal is exceedingly sensitive we may vary the ma- 
nipulation by removing the central portions of the mass first, a 
thin layer of cerumen being left on all sides closely adherent to 
the walls of the meatus; this tubular remnant is then broken 
down by introducing the curette into the channel thus prepared, 
when, by pressing the instrument toward the wall of the mea- 
tus, the included fragment may be extracted. Sometimes it is 
difficult to tunnel into the centre of a mass of cerumen on ac- 
count of the extreme sensitiveness of the canal. This is particu- 
larly true of cases in which unsuccessful attempts have been 
made to remove the cerumen before the case comes into the 
hands of the otologist. In these cases the canal is frequently 
swollen and its lumen so narrowed that all manipulation is diffi- 
cult, while the Avails are so exquisitely sensitive to pressure 
that any attempt to tunnel into the mass causes the patient 
severe pain. In some of these cases the application of peroxide 
of hydrogen to the centre of the mass by means of a cotton- 
tipped applicator has so softened the cerumenous plug as to 
admit of its easy removal, either with the curette, the cotton- 
tipped probe, or the syringe. If the operator should be so un- 
fortunate as to rupture the membrana tympani, the first care 
should be thoroughly to cleanse the entire field by means of 
an antiseptic solution, and thus reduce to a minimum the 
chances of infection of the tympanum. 

A rather curious condition which was observed in one of 
my cases was the sudden effusion of a large quantity of serum 
into the middle ear following the removal of a mass of impacted 
cerumen which had lain in the canal for many years. The only 
explanation that could be offered in this case was that the blood 
vessels of the tympanum had been so compressed by the ac- 
cumulation within the canal that they had lost their tone. The 
removal of the mass subjected them quite suddenly to the pres- 
sure of the blood current, and resulted in a rapid transudation 
of the fluid elements of the blood; in this case a minute rupture 
of the atrophic drum membrane occurred. A few hours after 
the operation the patient was suffering- intense pain; the middle 
ear was full of a sero-sanguinolent fluid, which passed out as 
rapidly as possible into the canal through the small perforation 
which had been made. Feeling confident that no inflammatory 
condition could be present in so short a time, as strict antiseptic 
precautions had been taken throughout the entire procedure. 



2 ;8 IMPACTED CERUMEN. 

the pain was attributed simply to the pressure of the fluid within 
the tympanum. A long incision close to the posterior attach- 
ment of the membrana tympani to the tympanic ring evacuated 
the fluid, the knife dividing the mucous membrane upon the 
internal tympanic vail at the same time that the section of the 
drum membrane was effected. Relief was immediate, and in 
thirty-six hours the opening had closed completely, the patient 
regaining perfect hearing at the end of ten days. 

After a large mass of cerumen has been removed, it is well 
to insert a pledget of cotton into the meatus, directing the pa- 
tient to remove it upon retiring for the night, after which it 
need not be replaced. Since these masses ordinarily contain a 
certain number of parasitic vegetable organisms, the patient 
should be seen once or twice subsequently to guard against the 
development of these parasitic growths. It is advisable during 
the interval between the visits that an alcoholic solution either 
of boric acid, in the proportion of forty grains to the ounce, 
or of salicylic acid, ten grains to the ounce, should be instilled 
into the canal twice daily; this will effectually destroy any vege- 
table spores which may remain, and render a reaccumuiation 
less liable to occur. This plan of treatment is also indicated, 
since, in removing the mass, it is not unusual that small areas 
may be abraded and render the occurrence of an acute circum- 
scribed external otitis probable. Xo case should be considered 
thoroughly cured until the entire cutaneous lining of the mea- 
tus is perfectly normal. 



CHAPTER XIV. 

FOREIGN BODIES IN THE CANAL. 

JEtiology. — We have already described, under Impacted 
Cerumen, the various symptoms which may arise from the 
presence of any foreign substance within the external audi- 
tory canal, but here the presence of the foreign body in the 
canal is due to natural causes. The symptoms occasioned by 
a foreign body in the external auditory canal, which has 
either developed there spontaneously or has obtained lodg- 
ment there by accident or design, are exactly similar. We 
shall therefore omit a repetition of the symptomatology, and 
confine ourselves to the consideration of the nature of the 
substances which are met with in this locality, and the meas- 
ures which may be necessary to effect their removal. 

Pathology. — These foreign substances may be divided 
into two great classes : the inorganic and organic. The inor- 
ganic substances which have been removed from the external 
meatus are almost infinite in number. Children seem to take 
special delight in introducing into the meatus any article 
which can be made to enter it. Thus we frequently find 
buttons, glass beads, pebbles, sand, broken glass — in fact, 
anything which chance may throw in their way — introduced 
into this passage. A pernicious habit, frequently adopted, 
is the introduction of cotton into the ears of a child when 
it is taken out of doors on a cold day ; the mother often 
neglects to remove this, and the child may subsequently 
crowd it deeply into the meatus in its efforts to dislodge it. 
In this situation it may remain, often for many years, and it is 
not uncommon in dispensary practice to find a small plug of 
cotton forming the nucleus of a mass of impacted cerumen, 
the patient being unable to state when the foreign substance 
was introduced. 

Among the organic substances found are apple seeds, 
watermelon seeds, cherry pits, the shells of edible nuts, small 

(270) 



28o FOREIGN BODIES IN THE CANAL. 

pieces of straw which have been used by the patient to 
scratch the ear, or minute splinters of wood which may have 
been broken off in the canal during a similar effort on the 
part of the patient. Occasionally the body of a dead insect 
is found, the insect having gained entrance to the meatus 
accidentally, and, being unable to escape, has remained there 
until removed by artificial measures. A living insect usually 
causes such marked symptoms by its presence in the canal 
that immediate efforts are instituted for its removal. When 
leeches are carelessly applied to the region of the ear — the 
meatus being allowed to remain open during the operation — 
the animal may detach itself from the point of application, 
and, making its way into the meatus, may attach itself to the 
drum membrane and cause intense suffering. Sometimes the 
eggs of the common house-fly are deposited in the canal and 
subsequently become developed into living insects, constitu- 
ting a condition distressing to the patient and disgusting to 
the observer. 

Symptomatology. — Very little need be said about the 
symptoms produced by a foreign body, as we have already 
discussed the subject thoroughly under Impacted Cerumen. 

That a foreign substance may lie in the meatus for a num- 
ber of years without giving rise to any symptoms, and then 
suddenly make its presence felt by manifestations of unusual 
severity at first, appears strange ; yet this is easily under- 
stood, if we consider that an irregularly shaped body may, 
in this locality, exert no pressure on the surrounding walls, 
but if suddenly displaced ever so little may impinge upon 
delicate and sensitive parts. Any foreign substance which 
increases in volume by the absorption of moisture is particu- 
larly liable to produce symptoms of increasing severity. 
Beans or seeds which when dry may be easily dropped into 
the canal become moistened by perspiration, and attain such 
a size that their spontaneous exit becomes impossible. While 
this increase in volume may not be sufficient to constitute a 
source of discomfort, the introduction of water into the 
meatus while bathing may bring about this result. Again, 
if there is at the same time a suppurative otitis media, the 
discharge from the tympanum will cause a foreign body to 
increase in volume. The local irritation which a foreign 
body exerts upon the walls of the canal increases the secre- 
tion from the cutaneous lining, the superficial epithelium is 



DIAGNOSIS— PROGNOSIS. 28 1 

thrown off rapidly, and the canal is filled with these white, 
moist scales. This condition is particularly favorable for the 
development of the various forms of parasitic growths, or of 
a local infectious process ending- in a circumscribed or diffuse 
inflammation of the walls. Naturally all of these manifesta- 
tions are more common among the classes who pay little 
attention to personal cleanliness, or are exposed to surround- 
ings which render local infection especially easy. 

When the middle ear is the seat of suppuration, the for- 
eign body may interfere with proper drainage, and then 
symptoms of pus retention ensue. 

Diagnosis. — The recognition of any foreign substance 
lying within a perfectly patulous canal is exceedingly sim- 
ple. Unfortunately, however, these patients are seldom seen 
immediately after the introduction of the foreign body and 
before efforts have been made to effect its removal. These 
attempts at the hands of the patient are necessarily unskillful, 
and result in the infliction of considerable injury to the sur- 
rounding parts. If the case is inspected at the end of a few 
days, the canal may be so swollen that the deeper parts are 
entirely invisible, the softer tissues prolapsing about the for- 
eign body and completely hiding it ; while at the same time 
the secretion from the parts, the desquamated epithelium, 
and the presence of dried blood which has followed the efforts 
at removal, so distort the normal appearance that an exact 
diagnosis is a matter of great difficulty. The parts may be 
so tender that only the smallest speculum can be introduced, 
while manipulation may be impossible. Under these condi- 
tions, our diagnosis must depend entirely upon the history ; 
when this clearly indicates the nature of the affection with 
which we have to deal, it is unwise to prolong the examina- 
tion, as the indications for treatment are identical, no matter 
what the nature of the substance may be. 

Prognosis. — The outcome of the condition will depend 
more upon the local disturbance which is present than upon 
the nature of the foreign body or its location. The parts in 
some cases are exceedingly tolerant, while in others compara- 
tively harmless substances may give rise to severe symptoms. 
Probably nothing increases the gravity of a case to such an 
extent as unsuccessful attempts at removal, the bodv itself 
doing less harm than unskillful efforts in this direction. 

When the condition has existed for a considerable period. 



2 32 FOREIGN BODIES IN THE CANAL. 

the presence of profuse purulent discharge will indicate that 
the tympanum has been invaded, while involvement of the 
mastoid ceils or interference with the outflow of pus will be 
evidenced by characteristic signs. 

Treatment. — The instrument which should be employed 
for the relief of this condition is the ear syringe. It is prob- 
ably safe to say that our first efforts should always be to clear 
the canal, if possible, by this means alone. Although it may 
seem perfectly simple to remove the foreign bodv with the 
forceps, with hooks, or similar instruments, attempts to grasp 
hard, smooth objects usually result in crowding them deeper 
into the canal, where they become impacted and are removed 
with great difficulty. A stream of water thrown with con- 
siderable force into the meatus is usually sufficient to dislodge 
any obstruction, while it inflicts no violence upon the parts. 
The only instance in which it may be wise to attempt re- 
moval by manipulation is in the case of seeds or dried vege- 
table substances, which may increase in volume so rapidly 
when moistened as to fill the canal completely. If a sharp 
hook can be made to penetrate such a foreign bodv to a con- 
siderable depth, this is usually the simplest measure for its 
removal. Forceps should only be used where the bodv is 
thin and flat, and may be grasped easilv in the jaws. When 
the contour of the bodv is more or less spherical, the efforts 
to grasp it will usually result in the instrument slipping and 
actually crowding the obstruction toward the fundus of the 
canal. Continued efforts in this direction may often force the 
object against the tympanic membrane, and even into the mid- 
dle ear. It is sometimes possible to introduce a blunt curette 
between the object and the canal wall until the instrument 
nas passed the obstruction ; the instrument is then withdrawn, 
and the foreign bodv removed with it. It may be necessarv. 
in the case of small, soft objects, to disintegrate them in the 
canal by instruments, and remove them piecemeal. This is 
particularly true of seeds, the shell being broken, and the 
soft interior removed by the curette, after which the remain- 
der of the shell can be easilv taken away. 

The necessity of anaesthesia must be determined in each 
individual case. It is an error, however, to prolong the 
efforts at removal where the patient is extremelv nervous, on 
account of the damage which mav be done to the surround- 
ing parts ; and. unless they meet with prompt success, the 



TREATMENT— EXTERNAL OPERATION. 283 

patient should be thoroughly anaesthetized before continuing 
the operation. In some rare instances, where the condition 
has been neglected, the meatus may become so small that it 
is impossible to extract the foreign body through the natural 
passage. Under these circumstances a more radical proce- 
dure becomes necessary. 

The patient being thoroughly anaesthetized, the parts 
above and behind the ear are shaved, thoroughly scrubbed 
with soap and water, washed with a i-to- 1,000 bichloride solu- 
tion and subsequently with ether, the external meatus hav- 
ing been previously syringed with a two-per-cent carbolic 
solution or some other antiseptic fluid, and tamponed with 
iodoform gauze. An incision is then made from just below 
the insertion of the lobule, upward along the line of attach- 
ment of the auricle to a point just above the meatus, and then 
forward as far as the helix ; the fibrocartilaginous canal is 
then loosened from its attachment by means of the periosteum 
elevator, the instrument being applied first below and then 
behind, the superior wall being detached last. In the same 
way the periosteum of the canal is separated from the bone, 
and the fibrocartilaginous tube is divided transversely as near 
the drum membrane as possible. 

This anterior flap, consisting of the auricle and the soft 
parts of the meatus, is turned forward, and entrance is thus 
gained to the bony meatus directly, and the path to the for- 
eign body is shortened by the length of the cartilaginous canal. 
This amount of gain is inconsiderable when we remember that 
the parts are covered with blood, and the view to a degree ob- 
structed by the haemorrhage. If the fibrous canal is swollen, 
as the result of secondary inflammation, and this is the only 
obstacle to the removal of the foreign body, we may be able 
to extract it at once after the flap has been turned forward. 
In case the object is found so firmly fixed in the canal that 
efforts at extraction are still futile, the lumen of the meatus 
can be enlarged with a chisel by carefully chipping away 
the bone from the posterior wall until sufficient space is ob- 
tained to remove the object. It is better to enlarge the pas- 
sage by the removal of a portion of the osseous wall than 
to attempt to extract the body by forcible manipulation. The 
operation presents no difficulties, and we should never delay 
in adopting this plan whenever extraction through the natural 
passage seems impossible. If, in our efforts, the tympanic 



284 FOREIGN BODIES IN THE CAXAL. 

cavity has been unavoidably opened, this feature does not 
add to the gravity of the condition. The parts should be 
thoroughly cleansed, and the wound in the tympanic mem- 
brane will soon close, and, as a rule, the middle ear suffers 
very little from the accident. After the purpose for which the 
operation has been undertaken is accomplished, the soft parts 
should be replaced, and the line of incision sutured by a con- 
tinuous subcutaneous catgut suture ; a rubber tube should 
be inserted into the meatus, both for the purpose of drainage 
and to keep the parts in position. Sufficient drainage is se- 
cured in this way, and primary union throughout the entire 
length of the incision should be looked for. If there is but 
little inflammatory change in the tissues of the meatus as the 
result of the presence of the foreign body, a light tampon of 
iodoform gauze may be inserted instead of the drainage tube. 
This should extend to the fundus of the meatus to secure 
proper drainage, and will be found to support the walls of 
the canal sufficiently. Unless the temperature indicates the 
necessity for doing otherwise, the dressing may remain un- 
touched for six days, when the parts will have united com- 
pletely. If there has been much previous laceration of the 
soft parts, it is usually wise to change the dressing at the end 
of the second or third day. If much discharge is found at 
this time the canal should be irrigated ; but if the parts are 
dry this is not necessary. The tube may be removed at the 
first dressing and the tampon of gauze substituted. The only 
unpleasant sequei which can result from the operation is the 
possible narrowing of the canal from cicatricial contraction, 
and this can be avoided if the parts are properly apposed 
after the operation and held in position for twenty-four or 
forty-eight hours. 



CHAPTER XV. 

EXOSTOSES OF THE EXTERNAL AUDITORY MEATUS. 

iEtiology. — The development of a new growth of an osse- 
ous character in the external canal has been attributed to 
various causes. It w r as formerly supposed that a gouty or 
rheumatic diathesis predisposed to the condition, although 
statistics fail to bear out this view ; and the same may be said 
of specific disease. 

Persistent irritation of the external auditory canal, espe- 
cially by the presence of a purulent secretion such as occurs 
in individuals suffering from neglected purulent otitis media, 
seems to be the most common certain cause for the develop- 
ment of these bony growths. Race also exerts a decided 
influence, the growths being more commonly met with among 
Europeans than among the inhabitants of our country, al- 
though among the aborigines they were of frequent occur- 
rence, as is proved by an examination of skulls discovered 
through archaeological research. The natives of the Ha- 
waiian Islands also manifest the condition quite commonly, 
and from their aquatic habits this fact lends great weight to 
the argument that the irritating action of salt water exerts a 
most important influence in the formation of these osseous 
growths. 

Their occasional occurrence in successive generations in 
the same family seems to point to a certain hereditary predis- 
position, although this is far from proved. 

Pathology. — The portion of the canal in which these 
growths are most frequently found is either the junction of 
the cartilaginous and bony meatus or the deeper portion of 
the osseous channel. They occur in two forms, either as dis- 
tinct pedunculated masses, or as protuberances from the bonv 
wall arising by a broad base. In structure they may be either 
cancellous or hard as ivory. A single bonv mass may be 
present, or, as more frequently happens, thev are multiple, 
projecting into the lumen of the canal from various aspects. 
20 (2S5) 



286 EXOSTOSES OF THE EXTERNAL AUDITORY MEATUS. 

Where the canal is obstructed by multiple growths, it 
preserves its circular form in a modified degree, the space 
left between the obstructing masses lying in the axis of the 
meatus. Where a single excrescence of large size is the cause 
of occlusion, the meatus is converted into a slitlike passage 
by the approximation of the growth to the opposite wall. 

Symptomatology. — A small bony tumor in the external 
canal gives rise to no subjective evidence of its presence, and 
even where the deposit is multiple the condition may be dis- 
covered only by accident. When they attain a sufficient size 
to obstruct the passage to a considerable degree, the func- 
tion of audition is interfered with. Certain other subjec- 
tive symptoms now make their appearance : the ear feels 
full and stopped up, there is autophonia, and quite commonly 
subjective noises. The normal secretion from the walls of 
the meatus may collect beyond the tumor, and, being unable 
to find exit on account of its presence, becomes impacted, 
and exerts a steadily increasing pressure upon the membrana 
tympani and the walls of the bony meatus. This pressure 
tends to increase the condition from the mechanical irritation 
which it causes. If the accumulation is not removed arti- 
ficially, the pressure may excite an acute inflammation within 
the middle ear, or an acute external otitis. This is especially 
prone to occur if water is introduced into the meatus, causing 
the mass to suddenly increase in volume. On the other hand, 
an acute inflammation of the middle ear, arising from another 
cause, may lead to serious results on account of the obstruc- 
tion to the exit of the fluid products of the inflammation. For 
this last reason exostoses of large size become a menace to 
life, and when once discovered the patient should be cau- 
tioned to submit to an examination periodically at the hands 
of an expert, in order that no extensive accumulation of ceru- 
men shall take place beyond the obstruction and cause com- 
plete occlusion. 

The degree to which these masses interfere with hearing 
varies considerably. Even when the meatus is exceedingly 
narrow the power of audition may not be noticeably impaired 
in the ordinary intercourse of life. 

Diagnosis. — Otoscopic examination usually renders the 
diagnosis clear at once. Where the growth is pedunculated, 
bulging, and broad, and especially if the surface is covered 
by a thin layer of cerumen, the examiner may at first be mis- 



DIAGNOSIS— PROGNOSIS. 287 

led as to the character of the obstruction, the appearance pre- 
sented in these cases being quite similar to epithelial debris 
mixed with cerumen closely applied to the wall of the meatus. 
Manipulation by means of the curette at once reveals the true 
character of the formation. Upon removal of the layer of 
dried secretion upon the surface by means of the curette, the 
integument is frequently found to be eroded and excessively 
tender to the touch. Undoubtedly the efforts of the patient 
to remove these crusts when the growth is near the orifice of 
the canal accounts for the steady growth in many instances. 
Located close to the drum membrane, and presenting as one 
or more small rounded protuberances, these bony excrescences 
may resemble closely a localized bulging in Shrapnel's mem- 
brane, but here again the probe reveals the true condition. 

The clinical history, and the resistance offered to the im- 
pact of the probe, discloses the true nature of the mass. The 
same points distinguish it from a circumscribed external otitis, 
or, where the neoplasm arises from a broad base, from a symp- 
tomatic diffuse otitis externa. 

Prognosis. — These neoplasms follow a different course in 
different cases. The progress followed by any individual 
growth is probably more dependent upon the causes opera- 
tive in its production than upon any other condition. Thus, 
if it is secondary to a purulent inflammation of the middle 
ear, the mass will undoubtedly increase in size until the irri- 
tating discharge has been controlled. Those cases depending 
upon diathetic conditions alone undoubtedly advance less rap- 
idly, and here the increase in size is seldom sufficient to de- 
mand operative treatment unless an intercurrent acute inflam- 
mation of the tympanum takes place, necessitating the removal 
of the exostosis to secure proper drainage. After removal 
the growth does not tend to reappear. We are seldom able 
to restore, however, the normal lumen of the meatus, even 
though the tumor is completely taken away. The local irri- 
tation which must necessarily follow the operation excites a 
certain amount of inflammation in the bony tissue which leads 
to hypertrophy of the wall of the bony canal, and consequent 
narrowing of its lumen. 

The possibility of an exostosis degenerating into a malig- 
nant neoplasm should be borne in mind, especially when it is 
situated near the orifice of the meatus and constitutes a source 
of local discomfort. Under these conditions the patient con- 



288 EXOSTOSES OF THE EXTERNAL AUDITORY MEATUS. 

tinually irritates the canal in this region by the introduction 
of the finger or some blunt instrument to relieve the pruritus 
— a process which serves to keep the integument over the 
bony growth denuded of its superficial epithelium. From 
this constant local irritation a benign osseous tumor may as- 
sume the form of an osteo-sarcoma. These remarks would 
scarcely apply to growths located in the deep canal. 

Regarding the function of the organ, the remarks already 
made concerning the increase in the size of the tumor may 
be taken as an index of its probable effect in this direction. 
Lesions of this character endanger life only when they act as 
an obstruction to free drainage from the more deeply situated 
parts when these are the seat of an inflammatory process. 

Treatment. — Where the exostosis is deeply located, of 
small size, and gives rise to no symptoms, operative treatment 
is unwarrantable. It is well, however, to keep the patient 
under observation, the ear being examined at long intervals 
to ascertain whether the growth is progressive or has ceased 
to increase in size. It is surprising how narrow the meatus 
may become and yet impair in no degree the function of 
audition. 

When multiple growths are present, if the hearing is not 
noticeably impaired, interference is scarcely called for, al- 
though the patient should be advised to submit to an occa- 
sional examination in order that any secretion which may 
have collected may be removed before it has become im- 
pacted so firmly as to prevent its dislodgment without great 
difficulty. Sea bathing should be interdicted, on account of 
the irritating effect of the salt water, and at the same time the 
patient should be cautioned against allowing fluid of any sort 
to enter the meatus, since by this means any collection of 
cerumen or of desquamated epithelial cells may become so 
augmented in volume as to excite severe pressure symptoms. 

Where the obstruction of the meatus is almost complete, 
so as to interfere with the function of audition, or where the 
slightest increase in size would entirely close the canal, it is 
our duty to remove the exostosis. The precise manner in 
which this is to be done will vary according to its location, 
its form, and the individual preference of the operator. 
When the growth springs from a narrow base, and is situ- 
ated near the entrance of the bony canal, it is usually an 
easy matter to separate it by a chisel introduced into the 



TREATMENT. 



289 



meatus, and if carefully conducted the procedure does not 
endanger the parts within the tympanum. When more than 
one growth is present, or when the condition occurs close 
to the drum membrane, or springs from an extensive attach- 
ment, this simple measure is not efficacious, as we have no 
means of protecting the deeper structures. Moreover, those 
growths, springing from a broad base, are usually of an 
ivorylike hardness, and are but little affected by chisels 
small enough to be introduced into the canal, the instrument 
frequently glancing from the surface of the tumor and inflict- 
ing serious injury upon the parts beyond. The surgical en- 
gine may be used in these cases, the base of the growth being 
perforated by means of fine drills, thus weakening its attach- 
ment to the wall of the meatus and permitting its removal 
with cutting instruments, or the entire obstruction may be 
cut away with a properly constructed burr. Where one is 
familiar with the manipulation of the dental engine, the oper- 
ation, if carried out in this manner, can be performed with 
greater safety than by any other method. 

Where the growth is so large as to render it impossible to 
discover the exact site of its attachment it is well to expose 
the orifice of the bony canal by an incision behind the auricle, 
and to displace the auricle forward so as to gain better access 
to the bony meatus. The operative technique is the same as 
that already detailed for the removal of foreign bodies. After 
this has been done, either the chisel, the drill, or the burr may 
be used, according to the preference of the operator. 

Where the growth is located upon the posterior wall it 
should be remembered that, although the tumor may be 
eburnated, the tissue of the mastoid itself is comparatively 
soft, and if the chisel is employed to remove the growth it is 
much simpler to remove a thin lamella from the mastoid, to- 
gether with the tumor, than to attempt to chisel through the 
base of the growth. Less traumatism is inflicted upon the 
surrounding parts by this procedure, and the ultimate result 
is correspondinglv more satisfactory. 

Where a purulent otitis media of long duration is present, 
exostoses of moderate size should be removed on account of 
the probability of a steady growth with the consequent ob- 
struction to free drainage. In such cases it would be much 
better to detach the auricle than to attempt to operate 
through the canal. If this is done, we may at the same time 



290 EXOSTOSES OF THE EXTERNAL AUDITORY MEATUS. 

remove all carious bone from the tympanum, and effect a cure 
of the purulent otitis. 

Concerning internal medication but little can be said. 
Anti-rheumatic remedies exert practically no influence upon 
the progress of the local condition, and it is only where a dis- 
tinct specific history can be elicited that we have any reason 
to hope for improvement following the administration of in- 
ternal remedies. If the osseous mass within the meatus is 
considered to be of syphilitic origin, the administration of 
large doses of iodide of potassium should be tried before re- 
sorting to operative procedures. Even in these most favor- 
able cases the results are often disappointing. 



CHAPTER XVI. 

WOUNDS AND INJURIES OF THE MEMBRANA TYMPANI. 

JEtiology. — The partition separating the middle ear from 
the external portion of the conducting mechanism may suffer 
injury either by direct violence from instruments introduced 
into the meatus, or its continuity may be destroyed by indi- 
rect violence, by the sudden condensation of the air within 
the meatus, as when a heavy gun is fired close to the ear, 
or when one is in the vicinity of a heavy explosion. From 
the anatomical structure of the drum membrane, we remem- 
ber that its superior portion is directly continuous with the 
integument of the superior wall of the meatus. Traction 
upon the auricle, therefore, especially in children, may pro- 
duce a rent in this portion of the membrana. Irritating sub- 
stances introduced into the canal for the relief of pain in 
the ear, or for toothache, may produce a superficial inflam- 
mation of the lining membrane of the canal and of the drum 
membrane ; in the same manner a vegetable parasite grow- 
ing within the meatus causes a diffuse external otitis. When 
moderate in degree, such an inflammation amounts to nothing 
more than a dermatitis, the superficial epithelium being exfo- 
liated and the deeper layers exposed. When the inflamma- 
tion is of greater intensity actual tissue necrosis takes place, 
and the drum membrane may be perforated, thus exposing 
the tympanic cavity not only to infection from the air, but 
also to the direct action of the substance which has excited 
the inflammation within the canal and has caused the perfora- 
tion in the membrana tympani. As a result of this we have 
inflammation of the middle ear grafted upon the already ex- 
isting inflammation of the external meatus. Perforation of 
the membrane from inflammation within the tympanic cavity 
is of secondary importance to the original disease, and pre- 
sents no characteristic features. 

Pathology. — From the introduction of instruments into 
the canal injury to the membrana tympani is usually effected 

(20 r) 



292 WOUNDS AND INJURIES OF THE MEMBRANA TYMPANI. 

in the upper and posterior quadrant, since this region is most 
accessible, the angle formed between the cartilaginous and 
bony canal protecting the anterior portion of the membrane 
from injury. When the rupture follows a sudden condensa- 
tion of air in the meatus, either from a blow upon the ear 
or from an explosion, the rent is most frequently situated in 
the postero-superior quadrant, from the fact that the greatest 
breadth of the tympanic cavity lies in this region. Owing to 
some irregularity in the position of the structure an accident 
of this character may produce a rupture in the anterior por- 
tion of the membrane. Following traction upon the auricle 
the upper part is most frequently torn, and here the rupture 
is usually confined to the region of Shrapnell's membrane, the 
membrana vibrans being to an extent protected by its loose 
attachment to the membrana flaccida. Openings into the tym- 
panic cavity are usually single when of traumatic origin, but 
occasionally multiple perforations are found. They vary in 
shape from a simple rent, the edges of which are only slightly 
separated, to an irregularly circular opening, as occurs when 
the force is considerable, or when the membrane is very tense. 
If the septum is tightly stretched the elasticity of the struc- 
ture separates the edges of the tear, giving the appearance of 
a certain loss of substance. 

Following the introduction of chemical irritants, the de- 
struction depends upon the activity of the chemical agent in- 
stilled. 

We have purposely omitted the cases of rupture follow- 
ing severe injuries of the cranium, since here the aural affec- 
tion is of but slight importance in comparison with the frac- 
ture of the base of the skull or the cerebral concussion. The 
drum membrane in these cases may be injured either by a 
blow upon the side of the head, which suddenly compresses 
the air within the canal, or by a blow upon the skull which, 
by the force of impact, subjects the bony ring to great pres- 
sure at one point, and causes it to yield slightly, rupturing 
the attached membrane. 

Where the middle ear becomes secondarily involved, the 
pathology does not differ from that of a middle-ear inflamma- 
tion from any other cause except in the fact that it is usually 
purulent. 

Symptomatology. — When the drum membrane has been 
torn, the first symptom is severe pain, referred to the deeper 



SYMPTOMATOLOGY— DIAGNOSIS. 



2 93 



part of the organ. Coincident with this there is a very de- 
cided impairment in hearing and the development of loud 
subjective noises. Vertigo ordinarily occurs following a blow 
upon the ear, but this is due rather to a sudden increase in 
labyrinthine tension than to rupture of the membrana tym- 
pani. Very soon the patient is conscious of a watery dis- 
charge within the meatus, and the acute pain which was pres- 
ent immediately after the injury becomes dull, throbbing, and 
more diffuse. Upon blowing the nose the attention is at once 
attracted by the passage of the air through the ear, with the 
production of a high-pitched whistling sound. If secretion is 
present the high-pitched note is followed by bubbling sounds 
as the air passes through the fluid. Where the rent is large, 
the pain is usually of shorter duration than when but a small 
opening is present. The reason of this is that the copious 
serous transudation which immediately follows the injury 
finds a ready means of exit from the tympanic cavity, and 
produces less pressure upon the parts than where but a small 
opening exists. 

The subsequent progress of the case will vary according 
as the middle ear is or is not involved. In the first instance 
a rather long-continued suppurative process not infrequently 
follows, while, if the tympanum escapes, the rent of its outer 
wall may close perfectly in a few days, leaving no symptoms 
behind. 

Diagnosis. — A recent rupture is easily made out on exami- 
nation, its irregular contour being marked by a delicate line 
where the rupture is linear (Fig. 91), or by an 
apparent loss of substance over the affected 
region where a circular opening is present. / jf* 
Through this opening the mucous lining of the / 



the [ J 

ovv- I WW i 

the \ 



middle ear appears red and congested, thro 1 
ing a bright reflex back to the eye from the 
moisture upon the inner tympanic wall. The _ 

r . r i FlG - 9 1 - — Linear 

history of traumatism in the region of the ear, rupture of the 
or of any injury to the skull, followed by an ^ brana tym " 
aural discharge, should lead to a careful ex- 
amination for any evidence of injury to the drum membrane. 
Where the rent occurs close to the margin of the ring it may 
escape recognition, unless the entire line of attachment of the 
membrane be inspected. Wounds in Shrapnell's membrane 
are less easilv recognized than those in membrana vibrans, 



294 WOUNDS AND INJURIES OF THE MEMBRANA TYMPANI. 

owing to the natural flaccidity of this part. Evidences of a 
previous rupture are the presence upon the surface of the 
drum membrane of minute blood clots, corresponding in 
position to the outline of the rent, and the coexistence of 
delicate radiating vessels along this line which impart a slight 
pinkish tinge to the affected area. These vessels become visi- 
ble, owing to the increased vascularity incident to the repara- 
tive process. The presence of minute blood clots in the 
meatus also points to a previous injury. These appearances 
are of practical value only in medico-legal cases, where we 
may be called upon to determine the effect on the ear of a 
previous injury. 

Prognosis. — An opening made into the tympanic cavity 
as a surgical procedure is one of the simplest operative meas- 
ures employed. It is quite different, however, if the open- 
ing occurs as the result of an accident, when the meatus may 
contain an abundance of infectious material, which thus gains 
access to the mucous lining of the tympanum ; here it is 
easily absorbed and produces characteristic results. 

On account of this, an accidental rupture of the mem- 
brana tympani at the hands of the surgeon in attempting to 
remove a foreign body, either with the syringe or curette, is 
seldom followed by untoward results ; while the same acci- 
dent inflicted at the hand of the patient might lead to fatal 
consequences. In the one case, if proper precautions have 
been taken, the parts are in a thoroughly aseptic condition 
before the traumatism has occurred, and hence no infection 
follows, while the reverse is true in the latter instance. 

In general, the prognosis both for the ultimate closure of 
the opening and the restoration of the power of audition is 
fairly good, if the case comes under observation before a 
chronic purulent inflammation has supervened. If this has 
occurred, the result will depend upon the condition of the 
parts as revealed by the examination, independent of the 
cause which has produced it. 

Treatment. — As the surgeon, no matter how expert, will 
occasionally wound the membrana tympani, no instrument 
should be inserted into the meatus before this channel has 
been thoroughly cleansed. Even in removing foreign bodies 
by means of the syringe, the solution employed should be 
antiseptic in character, in view of the fact that the tympanum 
may be accidentally entered. Under these conditions it is 



TREATMENT. 295 

only necessary to dry the parts lightly with cotton, dust a little 
boric acid along the margins of the wound, and occlude the 
meatus with a pledget of sterilized cotton. A little serous dis- 
charge may follow, in which case the patient is directed to 
change the cotton as frequently as it becomes saturated. No 
other treatment is necessary, the parts resuming their normal 
condition in from twelve to twenty-four hours, even when very 
free serous discharge has supervened. 

In cases where the membrana tympani has been ruptured, 
the surgeon should always secure perfect asepsis by scrubbing 
the meatus and the surface of the drum membrane with an alco- 
holic solution of bichloride of mercury, of a strength 1-3,000. 
If the parts seem comparatively dry, the perforation should be 
covered with a small disk of sterilized paper moistened in sterile 
albolene. This is carried into the canal by means of a delicate 
cotton-tipped probe. In cases of linear rupture of the mem- 
brana tympani this paper dressing serves to support the parts, 
to maintain the asepsis of the tympanic cavity, and to cause the 
wound to heal without the deposit of any appreciable amount of 
cicatricial tissue. Where the opening in the membrana tym- 
pani is larger, as in cases of stellate rupture, and where the 
margins of the wound in the drum membrane have sloughed, 
leaving an irregular opening, the application of this paper disk 
is of advantage as it supports the drum membrane during the 
process of cicatrization and prevents the formation of a relaxed 
cicatrix. These paper dressings should be applied only when 
there is practically no discharge from the ear or in cases where 
the discharge is very slight and is serous in character. 

When seen at a later period, or in cases where it is probable 
that infection has taken place, local bloodletting from the region 
in front of the tragus may abort the inflammation. If the open- 
ing through the drum membrane is exceedingly minute, and 
the middle ear contains a large amount of fluid, the wisest 
plan is to make a free incision through the drum membrane, at 
the same time incising the opposite internal wall of the tym- 
panum. This evacuates the contents of the cavity and depletes 
the vessels upon its inner wall. The measure is followed almost 
invariably by a prompt disappearance of the symptoms, the 
wound closing in from twenty-four to forty-eight hours. We 
sometimes meet with cases in which Nature has already sealed 
the opening by the deposit of a small blood clot upon the ex- 
ternal surface of the drum membrane. No attempt should be 



296 WOUNDS AND INJURIES OF THE MEMBRANA TYMPANI. 

made to remove this unless there is severe pain,, as healing in- 
variably takes place if the clot is allowed to remain. Interfer- 
ence with it may possibly infect the cavity and be followed by 
severe inflammation of the middle ear. Acute or chronic otitis 
media following the accident calls for the treatment indicated 
under the discussion of these diseases. 



Ill DISEASES OF THE MIDDLE EAR. , 

The entire middle ear, from the pharyngeal orifice of the 
Eustachian tube to the inner surface of the membrana tym- 
pani, is covered with mucous membrane; this is supplied with 
glandular structures, in some parts very richly, while in other 
parts they are rather sparsely distributed, for the purpose of 
keeping the membrane moist. 

The pathological processes met with here may involve 
either the entire region or some single portion of it. Consid- 
erable confusion exists at present in the classification of dis- 
eases of the middle ear, and many cases in which the Eustachi- 
an canal alone is affected are classified as cases of otitis media, 
while, on the other hand, certain manifestations within the tym- 
panum dependent not upon inflammatory changes, but upon 
certain conditions of the blood vessels distributed to the parts, 
are also considered under the same title. It should be remem- 
bered that the fluid effused in a simple inflammation of a mu- 
cous membrane is an increased amount of the normal secre- 
tion of the membrane, and nothing more. The presence of a 
purulent effusion as the primary result of such an inflamma- 
tory change in a cavity lined with mucous membrane is im- 
possible ; in order that the fluid shall be purulent, infection 
must take place from the outside, or the inflammation must 
be infectious from the first, and involve not only the mucous 
membrane, but the underlying connective-tissue structures. 
The affections in which the mucous membrane alone is in- 
volved have been denominated as catarrh of the middle ear. 
From the derivation of the term, this name indicates simply 
an increased amount of secretion. Such an inflammatory pro- 
cess may involve the Eustachian tube alone, giving rise to tubal 
catarrh or catarrhal salpingitis, or both the tube and the tym- 
panum may be involved, in which case we have a tubo-tvm- 
panic catarrh or salpingo-tympanitis. In this last-named dis- 
ease the inflammatory process is chiefly confined to the tube 
and seldom goes beyond the stage of congestion, changes tak- 

(297) 



298 DISEASES OF THE MIDDLE EAR. 

ing place in the cavity of the middle ear being almost entirely 
secondary to this and depending upon the physical condition 
of reduced pressure within the tympanum, due to closure of 
the Eustachian canal. The disease is really salpingitis, which 
secondarily has given rise to certain physical changes within 
the drum cavity discernible upon otoscopic examination, and 
scarcely deserves recognition as an individual affection. The 
separation of these two varieties is made more for convenience 
in classification than for any other reason. 

In other instances the tympanum is the primary seat of a 
superficial inflammation with no involvement of the connective- 
tissue framework. In such cases the changes are usually con- 
fined to the lower portion of the tympanic cavity or to the 
atrium. The epitympanic space is not involved, and the in- 
flammatory process results in the pouring out of an increased 
amount of normal secretion, which fills, more or less com- 
pletely, the middle ear. The mucous membrane covering the 
internal surface of the membrana tympani participates in the 
process, and the membrana may be so infiltrated as to rup- 
ture from the increased pressure caused by the pent-up secre- 
tion. The rupture of the membrane in such a case depends 
not so much upon a deep-seated inflammatory process as upon 
the increased pressure to which the membrane is subjected 
from the secretion within the cavity, although in severe cases 
it is probable that the entire thickness of the membrane is 
involved on account of the free anastomosis between the 
vessels of the inner and outer layers. After perforation has 
taken place this form of inflammation may become changed 
in character from the infection of the discharge from with- 
out, after which it runs the typical course of a purulent in- 
flammation. 

Such are the changes present in those cases where a sim- 
ple catarrhal inflammation occurs within the middle-ear tract. 
Both in tubo-tympanic catarrh and in acute catarrhal inflam- 
mation of the middle ear we may have a solution of continuity 
in the drum membrane ; in the tubo-tympanic form this rup- 
ture is due simply to the pressure of the fluid with which the 
cavity is filled. It is probable that rupture never occurs in 
these cases if the membrane is not atrophic from a previous 
pathological process. This fluid is not the result of inflam- 
mation, but of a serous transudation simply from the overdis- 
tended vessels. The fluid collects in the atrium although 



PLATE IX. 







4. 





5. 



6. 



Dr. W. A. Holden, ad. nat. del. 



EXPLANATION OF PLATE IX. 

i. Appearance of the membrane in tubal catarrh. Exaggeration of an- 
terior and posterior folds. Short process prominent. Malleus handle fore- 
shortened (indicating marked retraction). Light reflex lost. No evidences of 
congestion in membrane or tympanum. 

2. The normal membrana tympani. The congestion along the posterior 
border of the manubrium was due to the prolonged presence of the speculum 
in the canal. 

3. Otitis media purulenta residua, with caries of the malleus and incus* 
There is a small perforation above the short process. The malleus handle is 
adherent to the internal tympanic wall, which is partially covered with a non- 
secreting membrane. This is wanting posteriorly over the niche of the round 
window, and anteriorly over the entrance to the Eustachian tube. 

4. Purulent otitis media, with extensive destruction of the membrana 
vibrans and displacement of the ossicles. The long arm of the incus, the 
posterior crus of the stapes, and the niche of the round window are visible. 

5. Chronic catarrhal otitis media (hypertrophic form). Malleus shaft 
rotated upon its long axis and apparently increased in breadth. There are 
several areas of calcification in the membrane. 

6. Serous effusion in middle ear, with congestion of membrana flaccida. 
The level of the fluid is distinct. This condition is often present in tubo- 
tympanic congestion. 

(29S a) 



PLATE X. 





7. 





10. 





11. 



12. 



Dr. W. A. Holden, ad, nat. del. 



EXPLANATION OF PLATE X. 

7. Chronic catarrhal otitis media (hyperplastic changes subsequent to 
hypertrophic inflammation). Membrane retracted. Malleus handle fore- 
shortened, and apparently narrow from rotation upon long axis. Adhesions 
beneath membrana flaccida, as shown by depression above short process. 

8. Retraction of membrana tympani, with slight foreshortening of the 
malleus handle. This appearance is often observed in patients with enlarge- 
ment of the pharyngeal tonsil, who suffer from repeated attacks of tubal or 
tubo-tympanic congestion. The membrane becomes relaxed and attenuated, 
and sinks inward upon the internal tympanic wall, so that the long arm of 
the incus and the incudo-stapedial articulation are easily recognized. 

9. Intense congestion of membrana flaccida and of manubrial plexus. 
The membrana vibrans normal in parts not adjacent to extensive vascular 
plexus. Such an appearance characterizes the first stage of acute purulent 
otitis media. 

10. Acute purulent otitis media, with bulging of membrana flaccida and 
displacement of adjacent wall of meatus. The membrana vibrans is partially 
hidden, but the portion visible is normal in color. 

11. Chronic purulent otitis media. There is a perforation above the short 
process, through which a mass of granulation tissue protrudes. The mem- 
brana vibrans is wanting over the tympanic orifice of the Eustachian tube. 

12. Otitis media purulenta residua. Perforation in posterior inferior quad- 
rant. The appearance is characteristic of acute congestion as it occurs in 
these cases. The turgescence is confined to the regions richly supplied with 
blood vessels. 



(298 b) 



PRELIMINARY OBSERVATIONS. 299 

transudation may take place from the numerous reduplica- 
tions in the upper part of the cavity, the fluid entering- the 
atrium in obedience to the laws of gravity. In acute catarrhal 
tympanitis the transudation is of inflammatory origin, and 
this inflammatory process may be a factor of some impor- 
tance in causing the rupture of the membrane, although it 
is certainly not the principal one. Here the atrium alone is 
affected, although the tympanic vault may be involved sec- 
ondarily from subsequent infection of the discharge. 

Where the inflammation is purulent from the start we have 
those structures primarily involved which are richly supplied 
with connective-tissue elements. By recalling the anatomy of 
the tympanic cavity we remember that the vault of the tym- 
panum contains numerous duplicatures of mucous membrane, 
these being so fully developed in some instances as to com- 
pletely fill the entire epitympanic space ; the connective-tissue 
framework of these folds presents a favorable site for the 
growth of the bacteria of suppuration. When infection of 
this tissue occurs we have an inflammation set up which dif- 
fers in no respect from a cellulitis in any other portion of the 
body ; tissue necrosis takes place quite rapidly, and the secre- 
tion resulting from the inflammation is purulent in character 
from the outset. The fluid products find exit either into the 
atrium and then into the canal, or the membrana flaccida may 
be ruptured and an outlet afforded in this way, or the secre- 
tion may find its way into the mastoid cells or even into the 
cranial cavity when egress in other directions is prevented. 
Purulent inflammation occurs, as we should expect, in the 
more severe types of acute infectious diseases such as scarla- 
tina, diphtheria, variola, general pysemic infection, etc. As 
above stated, it may occasionally follow a simple catarrhal in- 
flammation by infection of the discharge and subsequent in- 
oculation of the connective tissue in the tympanic vault 
through this secretion. 

Under the forms of chronic inflammation involving the 
portion of the conducting mechanism under consideration, we 
have those resulting directly either from a previous simple 
catarrhal inflammation or from a purulent process. 

We include in this group those cases which give the history 
of repeated attacks of acute middle-ear inflammation, but in 
whom the membrana tympani is not perforated. Other cases 
present in which the membrana tympani has been destroyed 



300 



DISEASES OF THE MIDDLE EAR. 



over a small or large area and a permanent perforation remains. 
These again divide themselves into cases in which the discharge 
still continues after the acute disease has run its course, and 
those in which the residue of the former attack remains, the 
affection having either ceased spontaneously or yielded to treat- 
ment, restitution of the necrosed parts not having taken place. 

A third class of cases comprises that variety where the in- 
flammation is chronic from its inception and is characterized by 
a deposit of new tissue. To this we give the term hyperplastic 
inflammation. Although we may find this condition where a pre- 
vious purulent inflammation has existed resulting in local necro- 
sis, it is usually met with where no such loss has taken place. 
No sharp dividing line can be drawn between this variety and 
those following an acute catarrhal inflammation which has failed 
to resolve, and to which the term hypertrophic is applied. 

Regarding the particular bacteriological infection which oc- 
curs in various intratympanic inflammations, much has been 
written of late. From the rather free communication between 
the tympanum and the external air by way of the Eustachian 
tube, it would seem almost impossible that the tympanic cavity 
could ever be entirely free from pathogenic organisms. It is 
a well-known fact that repeated examinations of secretions of 
the mouth, the oro-pharynx and the naso-pharynx, in a large 
number of healthy individuals, will reveal the presence of vari- 
ous forms of bacteria, some of which are entirely harmless, 
while others are of the pathogenic variety. When we consider 
that the middle ear, under normal conditions, is practically in 
direct communication with both the nasal and naso-pharyngeal 
cavity, it would seem that an absolutely sterile tympanic cavity 
would be rarely met with. The investigations of Presing * 
would seem to show that under normal conditions the tym- 
panic cavity contains absolutely no bacteria of any description. 
Hasslauer.f in a series of similar investigations, has appar- 
ently proved that the normal tympanic cavity frequently con- 
tains a large number of various micro-organisms, among which 
may be mentioned diplococci, diplostreptococci, Friedlander's 
bacillus, the bacteria of decomposition, and occasionally strep- 
tococci. From these latter investigations, it seems probable 
that the presence of various forms of pathogenic organisms is 

* Centralbl. f. Bakter., vol. xxv, Abth. I, p. 635, Die gesunde menschliche 
Paukenhole ist keimfrei. 

f Klinische Vortrage aus dem Gebiete der Otologie und Pharyngo-Rhinologie, 

p. 83. 



PRELIMINARY OBSERVATIONS. 301 

not uncommon within the tympanum. With the mucous lining 
of the tympanic cavity in its normal condition these germs are 
not present in sufficient quantities, nor are they sufficiently 
active to cause any disturbance. If, however, the circulation 
within the tympanum becomes disturbed in any way, so as to 
render the tissues more vulnerable, then these organisms begin 
to proliferate within the middle ear, and to give rise to symp- 
toms characteristic of their presence. As before stated, most 
of these micro-organisms reach the middle ear by way of the 
Eustachian tube. It must be remembered that in the course 
of general systemic infections, such as diphtheria, measles, epi- 
demic influenza, and so forth, infection of the tympanic cavity 
may take place through the blood and lymph vessels. The 
precise character of infection causing a middle ear inflamma- 
tion, therefore, will depend upon several factors. In the first 
place, those inflammations of the tympanic cavity occurring 
primarily, and not complicating an acute infectious disease, are 
most probably dependent upon micro-organisms whose pres- 
ence in the tympanic cavity is adventitious and their develop- 
ment depends upon some temporary congestion of the mucous 
membrane within the middle ear from any slight external 
cause, such an exposure to cold, external traumatism, and so 
forth. In those cases of middle-ear inflammation complicating 
an acute infectious disease, such as measles, diphtheria, scarlet 
fever, epidemic influenza or pneumonia, a bacteriological inves- 
tigation has demonstrated clearly the presence of various or- 
ganisms in the discharge from the ear, the secretion examined 
being obtained either by paracentesis of the membrana tym- 
pani or the inoculation of the culture tube being made from the 
discharge present in the canal after spontaneous rupture of the 
drum membrane. In some cases of diphtheria, influenza, and 
pneumonia, the specific micro-organism of these diseases has 
been found in the discharge from the ear.* In many other 
cases, however, of the acute infectious diseases, especially of 
scarlet fever and measles, the infection has been due to vari- 
ous varieties of streptococci, staphylococci, and diplococci. 
As in many of these constitutional diseases the nasopharynx 
is frequently invaded, by an acute inflammatory process, the 
cultures from this region show the presence of those micro- 
organisms mentioned above. It seems probable, then, that 
the tympanic cavity was invaded directly through the Eu- 

* Hasslauer, loc. cit. 



302 



DISEASES OF THE MIDDLE EAR. 



stachian tube, and that an inflammation of the middle ear was 
determined, first, by the presence of a large number of these 
specific micro-organisms being introduced into the cavity, and, 
second, by the increased vulnerability of the mucous membrane 
of the middle ear, dependent upon the lowering of the general 
resisting power of the patient, due to the general constitutional 
infection. Clinically, we know that certain cases of acute in- 
flammation of the middle ear are exceedingly prone to be fol- 
lowed by an involvement of the bony structures about the ear — 
that is, to mastoid inflammation — while in other cases the pa- 
tient escapes without any such complication. Bacteriological 
investigation has shown that in two-thirds of the cases compli- 
cated by mastoid inflammation, a streptococcus is the micro- 
organism most frequently found.* 

While the study of the various forms of bacteriological in- 
fection of the tympanum is interesting to those devoted to 
laboratory research, the chief interest to the otologist is the 
determination of the prognosis in a given case by means of a 
bacteriological investigation of the discharge from the ear. In 
the present state of medical science, it is always wise to make a 
culture of an aural discharge at an early date, whether this dis- 
charge appears spontaneously or is evacuated as the result of 
an incision in the drum membrane. The culture is easily made 
by inoculating one of the sterile agar tubes, furnished by the 
Board of Health, a sterile cotton swab being introduced into 
the meatus so as to mop up a little of the discharge, and then 
carried lightly across the surface of the agar. At the same 
time, it is wise to make one or two smears on sterile microscopic 
slides, these smears being dried and then examined microscop- 
ically after staining. The presence of a large number of strep- 
tococci in the smears or in the culture tube, should always lead 
the surgeon to give a doubtful prognosis as to the favorable 
outcome of the case. That is, where streptococcus infection is 
present, where these micro-organisms are found in large quanti- 
ties, and where the growth of the culture tube is rapid, the 
patient is much more liable to suffer from mastoid involve- 
ment than where a milder form of micro-organism is found. 

The behavior of any of the bacteria obtained in this way, 
when grown upon various culture media, will, in certain in- 
stances, materially influence the surgical procedures to be 
adopted in any given case. What has been said in regard to a 

* Hasslauer, loc. cit., p. 51. 



PRELIMINARY OBSERVATIONS. 



303 



streptococcus infection applies equally well to infections due 
to various other micro-organisms, it being remembered, how- 
ever, that the streptococcus is a germ of great virulency, and 
one which having once invaded the tissues yields less rapidly 
to mild measures of treatment than do the other forms. We 
find many cases in which the various forms of diplococcus — 
particularly the pneumococcus — lead to involvement of the 
bony structures about the ear. In a doubtful case, therefore, 
the surgeon should always bear in mind that the rapidity of 
growth of any germ in the culture medium is a moderately fair 
index of the rapidity with which the healthy tissues will be 
invaded. If the micro-organism is of slow growth, and if the 
smear preparations show only a few micro-organisms, then the 
surgeon is warranted in giving a favorable prognosis at once, 
and is perfectly justified in assuring the patient that involvement 
of the osseous tissues will not occur. Moreover, he is justi- 
fied in attempting to abort the acute inflammatory process by 
the local application of cold, where, if the affection were more 
virulent in character, such abortive measures of treatment 
would be entirely unjustifiable. It must also be borne in mind 
that in some cases of acute inflammation of the middle ear, 
where there is marked bulging of the membrana tympani and 
where incision of this structure is imperative, the examina- 
tion of the fluid may show the discharge to be entirely free 
from micro-organisms. I have recently seen such a case com- 
plicating a mild attack of measles, in which the drum membrane 
bulged extensively in the lower and posterior portion. The 
membrane would certainly have ruptured had it not been 
promptly incised. Careful cultures made from the fluid evacu- 
ated by incision of the membrana tympani revealed absolutely 
no bacteria. This goes to show that under certain conditions 
the circulation within the tympanum may be so interfered with 
that we may have what may be termed a " passive " effusion 
into the tympanic cavity, just the same as we have an effusion 
into the pleural cavity in cases of chronic cardiac or renal dis- 
ease. We may then have a discharge from the ear, the fluid 
being present in such great quantities as to rupture the drum 
membrane with pressure. The pain in these cases may be 
severe. If the case is treated aseptically, however, and infec- 
tion is not allowed to occur from without, the surgeon can 
assure the patient that he will make a perfect recovery without 
further operative interference. 



CHAPTER XVII. 

TUBAL CONGESTION, OR TUBAL CATARRH. 
(Acute Salpingitis. Eustachian Catarrh.) 

Etiology. — This affection of the Eustachian tube usually 
arises from an acute coryza or an acute nasopharyngitis, 
although it may be met with as a primary affection from 
exposure to cold. Occasionally it complicates light attacks 
of the exanthemata in young adults. It may depend upon 
the entrance of some irritating fluid into the Eustachian tube 
while bathing, or in using the nasal spray. Rarely it follows 
a blow upon the external surface of the body in this region. 
The chief predisposing cause is some obstructive lesion of 
the nose or naso-pharynx. The presence of adenoid vegeta- 
tions is a particularly potent factor in its causation, since 
these masses easily become engorged with blood, causing 
venous hyperemia of the walls of the tube, narrowing or com- 
pletely closing its lumen. At the same time, the presence of 
this soft tissue in the vault of the pharynx affords lodgment 
to pathogenic bacteria inhaled during the act of inspiration,, 
from which locality they easily find their way into the canal. 
Impaired general health, no doubt, renders one more liable 
to the disease. 

Pathology. — The pathological conditions are to be con- 
sidered under two heads : 

First, the actual changes present in the tubal mucous 
membrane. 

Second, the changes occurring in the middle ear depend- 
ent upon the obliteration of the tubal lumen. 

Within the tube the condition is essentially one of simple 
venous hyperasmia, or the membrane may be the seat of a 
very mild inflammation following the venous engorgement. 
The mucous membrane becomes swollen and flabby, the walls 
of the tube lying in contact with each other and adhering 
closely on account of viscid secretion. The first change of 

(304) 



SYMPTOMATOLOGY. 305 

venous hyperaemia results in a transudation of the fluid ele- 
ments of the blood from the increased pressure. When the 
process becomes fully developed, the secretion is thick, tena- 
cious, glairy, white in color, and by its presence may occlude 
the channel completely. The changes are usually most marked 
in the cartilaginous part of the tube, the osseous segment be- 
ing but little affected. 

When the Eustachian canal is obstructed from any cause 
the air contained within the tympanic cavity disappears quite 
rapidly from absorption. This results in diminished atmos- 
pheric pressure within the tympanum, and a crowding inward 
of the drum membrane and the entire ossicular chain by the 
external atmospheric pressure. If the canal remains closed 
sufficiently long, we shall find the drum membrane so dis- 
placed that it touches the opposite internal tympanic wall in 
the region of the tip of the long process of the malleus. At 
its upper and lower poles its firm attachment prevents dis- 
placement. 

Symptomatology. — An attack of this character, occurring 
in the course of an ordinary cold in the head, is usually char- 
acterized by a rather sudden onset of the symptoms. The 
patient complains of a feeling of stuffiness or heaviness in the 
ears, as though the external meatus were occluded by a for- 
eign body, one of the most characteristic symptoms being the 
desire to insert the finger into the meatus in order to " clear 
the ear," as the patient expresses it. This manipulation is 
sometimes attended by momentary relief from the exhaus- 
tion of the air within the meatus when the finger is suddenly 
withdrawn. Sometimes, in addition to this feeling of discom- 
fort, there is a sensation of actual pain referred to the upper 
part of the pharynx or the region of the tonsil. In rarer in- 
stances this pain is complained of in the region of the larynx, 
the sensation being as though a foreign body had become 
lodged at the root of the tongue. Accompanying this, there 
is some pain radiating upward toward the ear, but when 
closely questioned we find that no actual pain is present in 
the ear. 

The hearing is considerably impaired, the diminished audi- 
tion seeming more prominent from the sudden onset of the 
attack. Subjective noises are almost always present, and may 
be exceedingly distressing. They are most frequently high- 
pitched in character, and in plethoric subjects may increase 



306 TUBAL CONGESTION, OR TUBAL CATARRH. 

in intensity with each cardiac systole. Disturbances of equi- 
librium, from the sudden increase of labyrinthine pressure, 
may be met with, although their occurrence is not invariable. 
Among the rarer symptoms to which the affection gives rise 
is a feeling of heaviness and mental torpidity. In nervous 
subjects the anxiety of the patient as to the sudden impair- 
ment of hearing power is rather characteristic. The sensa- 
tion of heaviness within the ears may not remain confined to 
this region, but may be complained of as a stiff, numb feeling 
extending over the entire side of the head. It is seldom that 
both sides are affected to the same degree, although examina- 
tion will seldom show a perfectly normal condition in the 
organ which the patient asserts is healthy. 

Occasionally cases are met with in which an attack of tubal 
congestion follows any slight exposure to cold. While not 
severe enough to narrow the lumen of the canal to an extent 
which interferes sufficiently with audition to direct the atten- 
tion of the patient to the ear, the subjective symptoms are 
very pronounced. They consist in the sensation of a foreign 
body in the pharynx, or sometimes of an acute pain at the 
root of the tongue, occasionally severe enough to interfere 
with deglutition. The patient does not complain of the ear, 
but refers all the symptoms to the pharynx or larynx. These 
manifestations are met with most frequently among neurotic 
subjects, and the attacks may be repeated at short intervals. 
Occasionally they occur in individuals who are not neurotic, 
and in these patients the symptoms are more acute, and close 
questioning will usually elicit a history of a slight impair- 
ment of audition. 

Diagnosis. — A. Physical Examination. — An inspection by 
reflected light reveals the drum membrane drawn inward 
towards the internal tympanic wall, for which reason the in- 
ferior segment seems abnormally broad from above downward, 
w T hile at the same time the transverse diameter of this seg- 
ment seems to be increased (Fig. 92). The handle of the mal- 
leus is foreshortened, the short process is prominent and ap- 
pears lighter than normal, and in some cases it may be impos- 
sible to make out the contour of the manubrium, owing to the 
extreme degree of retraction, the shaft being entirely hidden 
behind from the prominent short process. Both the anterior 
and the posterior folds are exaggerated, the annulus tendino- 
sus is prominent, and the membrana flaccida may participate 



DIAGNOSIS. 



307 




in these changes, being drawn inward upon the neck of the 
malleus and closely applied to it, although this latter condi- 
tion is not ordinarily present. The color of the membrane is 
normal, its lustre is preserved, and the light 
reflex is either absent, displaced, or multi- 
ple. The stretching to which the parts have 
been subjected causes the membrane to ap- 
pear thinner than normal, and the under- 
lying intratympanic structures may be clear- 
ly discerned through it. In the upper and FlG - 92— Retraction 

J r 1 i °f membrana tym- 

posterior segment we are often able to recog- pan i f rom closure 
nize the long process of the incus, the in- of the Eustachian 
cudo- stapedial articulation, the posterior 
crus of the stapes, and sometimes the tendon of the stapedius 
muscle. The niche of the round window may also be visible. 
The lining membrane of the tympanum, as viewed through 
this thin covering, presents no evidences of congestion. The 
physical appearances are due entirely to the diminution of 
atmospheric pressure within the tympanic cavity, this region 
itself being unaffected. 

If the ear is inflated, either by means of the Eustachian 
catheter or by the Politzer method, the auscultation tube be- 
ing employed to furnish us with information concerning the 
condition of the parts, we shall find that the canal is opened 
with difficulty, the air either not entering the middle ear at all 
or only after several attempts at inflation. When the cathe- 
ter is used, the first few compressions of the bulb result in 
the production of a harsh, low-pitched, rasping sound, which 
we recognize as originating in the vault of the pharynx, and 
not depending upon the entrance of air into the middle ear. 
This is caused either by the current being forced through the 
thick viscid secretion with which the parts are covered, or 
by impinging directly upon the mucous membrane of the 
passage, which from the oedema is thrown into irregular folds 
and deflects the current of air from its original direction. As 
inflation is continued these pharyngeal sounds disappear, and 
the air enters the tube, either from the dislodo;ment of the 
mucus or from the displacement of the folds in the mucous 
membrane by manipulation of the catheter. Within the tube 
the current may meet an obstruction, either from an agglu- 
tination of the walls of the tube or from the lodgment of a 
mucous plug at the isthmus. When familiar with the auscul- 



308 TUBAL CONGESTION, OR TUBAL CATARRH. 

tatory signs we recognize that the sound produced by the 
insufflated air is nearer the ear, and is of a less harsh charac- 
ter than when the obstruction is at the pharyngeal orifice, 
while the sensation of the sound being produced close to our 
own ear is wanting. At last we recognize the entrance of the 
current into the tympanic cavity, the quantity of air entering 
being at first small and the sound produced by its passage 
being consequently high-pitched. If the swelling is exces- 
sive, the entrance of the air into the tympanum is irregular, 
instead of occurring freely with each compression of the bulb. 
When at length the lumen has been sufficiently cleared to 
permit the free entrance of the current, the sudden replace- 
ment of the drum membrane to its normal position is recog- 
nized by the examiner by the occurrence of a sharp, almost 
metallic click, as the membrane is forced outward. 

B. Functional Examination. — Upon testing the hearing, we 
find the power of audition for the whisper markedly reduced ; 
tests with the acoumeter and watch will also show reduction 
in the hearing power, although to a relatively less degree 
than to the voice. The lower tone limit is elevated, in the 
great majority of cases being above 32 V. D., and sometimes 
two octaves higher than this. The upper tone limit is fre- 
quently reduced, or it may be normal. When reduced, the 
change is caused by pressure upon the delicate structures 
lying in the lower turn of the cochlea. The bone conduction 
is augmented especially for the low notes of the scale, Rinne's 
experiment being negative for the lower notes and a reduced 
positive result being found as w r e ascend the musical scale. 
The vibrating tuning fork, placed upon the vertex or upon 
the forehead, is referred to the poorer ear in almost all cases. 
These reactions may be considered as typical, and will be 
found in a very large majority of instances. Certain condi- 
tions may exist, however, which will modify them, to which 
attention should be given. In patients over forty years of 
age the tuning fork may not be lateralized to the side most 
affected, and the bone conduction may not be increased in 
comparison with the normal standard. A similar change may 
be found upon applying Rinne's test. The remarks made in 
the chapter on Physiology upon the diminution of bone con- 
duction as age advances explain this apparent deviation 
from the classical reactions. When the patient is seen very 
early, and before much retraction of the membrana tympani 



FUNCTIONAL EXAMINATION. 



'309 



is present, we may find that the patient hears the lower notes 
of the scale fairly well, while at the same time bone conduc- 
tion is greatly diminished, and the upper tone limit lowered. 
This is probably due to a slight rarefaction of the air within 
the tympanum, which, according to Politzer, instead of in- 
creasing labyrinthine pressure, reduces it. It may also de- 
pend upon the particular susceptibility of the auditory nerve 
to mechanical irritation, causing a condition of hyperassthesia, 
which favors the perception of low notes, at the same time 
reducing bone conduction. 

These variations, while apparently confusing, in no way 
detract from the value of the functional examination, as they 
indicate the existence of a secondary labyrinthine condition. 
This interference with the perceptive apparatus is perfectly 
amenable to any treatment which will remove the tympanic 
disturbance upon which it depends, and its recognition is of 
importance since it shows, in any given case, a particular in- 
tolerance of the labyrinth to changes in pressure. 

It is not unreasonable to suppose that in any of these cases 
of sudden closure of the Eustachian tube the labyrinth suffers 
a certain amount of traumatism, the same as when the ear is 
exposed to the influence of sudden loud sounds, such as those 
produced by explosions, etc. It is a well-known fact that 
under these conditions a train of symptoms is found which 
we consider characteristic of concussion of the labyrinth. 
In the same manner, the sudden increase of labyrinthine pres- 
sure due to pressure of the stapes upon the perilymph may 
cause a condition of hyperassthesia of the auditory nerve, and 
change, to a marked degree, the reactions found on func- 
tional examination. When this occurs the case is one of laby- 
rinthine disease, acute in character, and readily amenable to 
treatment, and is due to the sudden and absolute closure of 
the Eustachian tube. Our functional examination reveals 
this labyrinthine condition, and should not be condemned be- 
cause it enables us to distinguish a complicating labyrinthine 
lesion, and emphasizes it rather more than the tubal stenosis. 
The clinical history and appearance of the drum membrane 
will render an error in diagnosis exceed ingly rare. When 
the auditory nerve is in a condition of hyperesthesia the per- 
ception of low tones is well preserved, and it may happen 
that the lower tone limit is not elevated to the degree which 
we should expect to find in sudden closure of the Eustachian 



310 TUBAL CONGESTION, OR TUBAL CATARRH. 

tube. Distressing tinnitus and vertigo, the latter being espe- 
cially prone to occur on inflating the middle ear, together 
with a lowering of the upper tone limit before inflation, 
render the diagnosis sufficiently clear. 

Prognosis. — Eustachian catarrh is ordinarily one of the 
simplest affections of the ear which it falls to our lot to meet. 
The only danger to the function of the organ lies in the tend- 
ency to a recurrence of attacks of this character. We have, 
then, to consider not only the outcome of the attack immedi- 
ately under observation, but also the result if it is allowed 
to repeat itself at short intervals. An attack of Eustachian 
catarrh ordinarily yields to treatment in from five to four- 
teen days. The hearing is completely restored only at the 
end of several weeks, but if by complete restoration we mean 
an absolutely perfect functional condition of the organ in the 
ordinary acceptance of the term, the patient notices nothing 
abnormal about the ear, either as regards the integrity of 
hearing or the presence of subjective noises after a lapse of 
five to fourteen days. After an individual has suffered from 
several attacks of this affection it will be found that the hear- 
ing gradually becomes impaired, each exacerbation reducing 
it somewhat, at first imperceptibly, but later in the course of 
the disease to a degree distinctly recognizable both by the 
patient and by those with whom he is brought in contact 
in his daily vocation. This is caused by the development 
within the tympanic cavity of a slowly progressive inflam- 
matory process, dependent upon the malposition of the con- 
tained parts for a long period of time. When the drum 
membrane is indrawn at frequent intervals by successive at- 
tacks of tubal stenosis, and remains in this position for a 
considerable period, it becomes stretched, and assumes an ab- 
normal position more easily than does the normal mem- 
brane. The tendon of the tensor tympanic muscle from re- 
peated relaxation becomes shortened, and exerts its influence 
in maintaining the irregularity of curvature which the mem- 
brane has assumed. This shortening of the tendon of the 
tensor causes the tip of the manubrium to press upon the 
internal tympanic wall. This source of mechanical irritation 
gives rise to an inflammatory process, ultimately resulting in 
the development of adhesions in other parts of the tympanic 
cavity, and producing a chronic catarrhal otitis media. Start- 
ing in this manner, we may have a simple hyperplastic pro- 



TREATMENT— INFLATION. 31 1 

cess developed, or the condition so much dreaded by the 
otologist and laity — sclerosis within the tympanic cavity. 
While, therefore, a simple tubal catarrh, if left to itself, will 
in all probability disappear at the end of a certain interval, 
we should never lose sight of the danger of frequent recur- 
rence, and it is our duty not only to relieve the single attack, 
but also to direct our efforts toward preventing a repetition. 

Treatment. — The treatment of the affection will embrace 
measures directed to 

First, the acute attack. 

Second, prophylaxis. 

When a patient suffers from the disease under considera- 
tion our first efforts are to relieve the subjective noises, the 
impairment of hearing and the feeling of discomfort within 
the ear, of which he complains. This is best accomplished by 
restoring the drum membrane to its normal position by some 
method of inflation. In adults there is no question but that 
the employment of the Eustachian catheter is the most effect- 
ive means at our disposal. In children, the Eustachian tube 
being relatively short and catheterization being attended by 
considerable difficulty, resort may be had to inflation by the 
Politzer method. When the catheter is used we shall find, as a 
rule, that the mucous membrane of the nares and naso-pharynx 
is intensely tender, owing to the inflammation in this region 
which has caused the aural disease. To overcome this and 
to render the process of catheterization less disagreeable to 
the patient, a ten-per-cent solution of cocaine should be first 
sprayed into the anterior nares, the anaesthesia being com- 
pleted by the passage of a cotton-tipped probe through the 
nares, the cotton having been saturated with cocaine solu- 
tion. The catheter is then introduced in the ordinary man- 
ner, when, by compressing the inflating bulb several times, 
the membrane is replaced. Care should be exercised in per- 
forming this manipulation to compress the bulb gently at first, 
as suddenly filling the tympanic cavity with air at this period 
is liable to cause intense dizziness, and the patient may even 
fall in a dead faint. By performing the inflation slowly, and 
gradually increasing the force until the tube becomes perme- 
able, this will be avoided. If the patient performs the act of 
deglutition at the moment the bulb is compressed, the air en- 
ters the cavity more easily. The relief is instantaneous when 
the malposition of the membrane is corrected, and the mental 



312 



TUBAL CONGESTION, OR TUBAL CATARRH. 



depression so common to these patients disappears at once. 
As the condition will undoubtedly return in from three to 
twenty-four hours after the first inflation, and from the sudden 
reappearance of the symptoms the individual may consider 
himself even worse than before treatment, it is always well 
to call attention to the probability of this recurrence. It is 
exceptional that a single inflation will permanently relieve 
the condition and the consequent symptoms. Sometimes the 
tube is so tightly closed that the air enters the middle ear 
only after repeated attempts at inflation. When this is the 
case the auscultation tube usually reveals the cause. This 
may be an oedema of the tubal walls, but more frequently is 
the lodgment of a plug of thick mucus in the tubal orifice, 
which completely prevents the entrance of air. This ob- 
struction may be removed by wiping the tubal mouth with 
a pledget of cotton, the extremity of the cotton carrier be- 
ing curved like the Eustachian catheter. After this has been 
done inflation becomes a very simple matter. The drum 
membrane being replaced, our next efforts should be directed 
to the abnormal condition within the tube. The site of the 
greatest oedema is usually the pharyngeal orifice, a part easily 
accessible to instruments introduced through the lower mea- 
tus of the nose. To control this oedema an astringent should 
be applied to the tubal mouth by means of a pledget of 
cotton, the cotton holder being bent in the form of the Eus- 
tachian catheter. None is better than a solution of nitrate of 
silver varying in strength from ten to thirty grains to the 
ounce. The degree of concentration suited to any particular 
case can be learned only by experiment, but in general the 
more acute the process the stronger the solution to be used. 
Concerning the application of vapors to the Eustachian tube, 
I do not believe this procedure to be wise in the early stages, 
as their action usually increases rather than diminishes the 
local congestion. The application of astringents seems not 
only more rational, but, clinically, is followed by better re- 
sults. The operation of inflation and topical applications to 
the pharyngeal orifice of the tube should be repeated at first 
daily, and later, as improvement becomes more marked, the in- 
terval should be prolonged to several days, until complete res- 
toration both of physical condition and of function takes place. 
In some cases it will be impossible to open the Eustachian 
tube by any method of inflation. Here resort must be had to 



TREATMENT— BOUGIE. 3 13 

the Eustachian bougie. I am in the habit of using for this 
either the bougie catheter (shown in Fig. 93), the dilatation be- 
ing effected by means of an olive-tipped metal bougie passed 
through the rings upon the back of the catheter, or, in the ab- 
sence of this, the ordinary Eustachian catheter, through which 
a piece of No. 5 piano wire is passed. The extremity pro- 





Fig. 93. — Author's bougie catheter for Eustachian tube. 



truding from the catheter is roughened slightly with scissors 
and armed with a pledget of cotton, care being taken to wind 
this so firmly that it can not be displaced. The wire is then 
drawn into the catheter so that the cotton-tipped end alone 
protrudes. Remembering that the diameter of the Eustachian 
tube varies from three quarters of a millimetre to two milli- 
metres, the size of this cotton pledget should certainly not ex- 
ceed the last-named dimension, and when used for the first 
time it is well to make it considerably smaller than this. The 
opposite end of the wire is bent at a right angle at a point one 
inch and a half from the outer funnel-shaped extremity of the 
catheter. This, then, enables us to estimate the distance that 
the bougie has passed into the tube at any time. The bougie 
catheter or the ordinary Eustachian catheter armed in this 
way is introduced in precisely the same manner as in per- 
forming the operation of inflation, after which the catheter is 
firmly fixed in position by the fingers, and the piano wire is 
made slowly to advance in the direction of the Eustachian 
tube, the patient being requested to swallow at frequent in- 
tervals, both to relax the faucial muscles and to increase as 
much as possible the diameter of the canal. After the instru- 
ment has passed about an inch beyond the pharyngeal orifice 
it will apparently meet an obstruction which will be recog- 
nized as the isthmus of the canal, the region at which the 
lumen is normally less than in other locations; aside from this 
any obstruction encountered constitutes a pathological condi- 
tion. In passing the instrument beyond such an obstruction 
the greatest gentleness must be employed, lest the mucous 
membrane of the canal be wounded and decidedlv uncomfort- 
able symptoms supervene. Most frequently in tubal catarrh 



3H 



TUBAL CONGESTION, OR TUBAL CATARRH. 



the obstruction is confined to the cartilaginous portion of the 
tube, the osseous segment remaining free. The use of the 
cotton pledget as a dilator has a twofold advantage. In the 
first place, the metal parts of the apparatus may be sterilized 
in boiling water, and if the pledget is formed of sterilized 
cotton it is impossible to introduce any pathogenic bacteria 
during the operation. A pledget of cotton tightly twisted in 
this manner increases in volume when moistened. If, there- 
fore, an obstruction is met with, and the instrument, after en- 
gaging it, is allowed to remain for a short time, considerable 
dilating force is exerted by the absorption of moisture, and 
a twofold advantage gained. Concerning the danger of the 
pledget of cotton becoming detached in the lumen of the tube, 
it can only be said that this has never occurred, and if ordinary 
care is used in the preparation of the apparatus no such acci- 
dent can follow. The necessity of thoroughly boiling the in- 
strument immediately before using it can not be too strongly 
emphasized. 

Where the lining membrane resists these efforts the appli- 
cation of astringents to the mucous membrane beyond the ori- 
fice is indicated. These may be made by moistening the cotton 
pledget previous to its introduction with a solution of nitrate 
of silver of various strengths, beginning with a weak solution, 
about five to ten grains to the ounce, and gradually increasing 
the strength until the desired result is obtained. Under no 
condition should inflation be practiced immediately after the 
introduction of a bougie, since a slight abrasion of the mucous 
membrane may furnish an avenue of entrance to the air and 
submucous emphysema may result. 

When the condition fails to improve at the end of ten days, 
stimulating applications in the form of vapors may be em- 
ployed with advantage. The object of such applications is 
temporarily' to increase local hyperemia, and, by means of this 
increased blood supply, to restore the tone of the parts and 
cause them to resume their normal condition. It makes but 
little difference what vapor is employed, so long as we bear 
in mind the object to be attained. Any preparation which is 
a local stimulant and vaporizes at the ordinary temperature 
may be used. Tincture of benzoin, oil of eucalyptus, menthol, 
iodine, camphor, and various aromatic oils may all be used 
with success; the vapor of alcohol, of ether, or of chloroform 
is also efficacious. The best method of exhibition is bv means 



TREATMENT— PROPHYLAXIS. 



3^5 



xtr'-fr^; 




Fig. 94. — Author's middle-ear vaporizer. The 
reservoir is fitted with stop-cock, and either 
air or medicated vapor can be insufflated at 
will by turning this. When the thumb-screw 
lies in the long axis of the inflating tube, air 
alone passes through the catheter ; when it is 
turned at right angles to this, medicated vapor 
is insufflated. 



of a device by which the current of air on its way to the 
tympanum is made to pass over the volatile substance, thus 
becoming charged with a certain amount of the volatile prin- 
ciple. Either Roosa's or 
Lucas's bulb, or the bot- 
tle devised by Dayton, 
or the instrument of the 
author (Fig. 94), may 
be employed, according 
to the choice of the 
operator. 

If the author's ap- 
paratus is employed, it 
is well, instead of filling 
the reservoir with the 
fluid, to place a little cot- 
ton saturated with the 
preparation to be used 
within this, as in the 

event of the accidental breaking of the reservoir by a sudden 
motion of the patient no damage is done to the garments 
either of the patient or of the physician. 

My own preference when vapors are employed is first to 
clear the tube as perfectly as possible by inflating with air alone, 
after which the inflation is continued with the medicated air. 
The strength of the application varies with the nature of the 
substance and with the condition of the parts. The menthol 
and camphor may be used in alcoholic solution in the strength 
of one drachm of each to the ounce of alcohol, or the solvent 
may be tincture of iodine, if the stimulating effect of the iodine 
seems indicated. The other drugs mentioned should be used in 
the same relative proportions. A third local stimulant of con- 
siderable value is a mixture of the oil of eucalyptus and pine- 
needle oil in equal proportions. Oil of cloves may be used in 
strength of half a drachm to the ounce of alcohol. When iodine 
is used, the officinal tincture is the preparation best suited for 
the purpose. Ether and chloroform should be used in exceed- 
ingly small quantities, as they are extremely irritating, and 
their use is attended by considerable discomfort. 

The advantages of inflating first with air and subsequently 
with a medicated vapor, instead of using the medicated air from 
the first, lie in the fact that by this means very little of the medi- 



316 TUBAL CONGESTION, OR TUBAL CATARRH. 

cated air is brought in contact with the mucous membrane of 
the nose and naso-pharynx, and local irritation here is reduced 
to a minimum. When medicated vapors are used the catheter 
is always the instrument to be employed for their introduction 
if this is possible. Occasionally, however, we may be obliged 
to resort to the Politzer method of inflation; but if possible this 
should be avoided. 

Under prophylactic measures must be included attention 
to the mucous membrane lining the nasal passages and the 
pharyngeal space. Inquiry into the history of these cases shows 
that the patients are subject to frequent " colds in the head or 
throat." If any departure from the normal condition is pres- 
ent in these regions it should be dealt with radically. The 
removal of enlarged faucial and pharyngeal tonsils, the reduc- 
tion of a hypertrophic process within the nares, either 'by 
chromic acid, the galvano-cautery, or any other appropriate 
measure, and the actual removal of any obstructive deformity 
of the septum or of an extensive hypertrophy of turbinated 
bodies which has failed to respond to less radical measures, will 
be necessary in order to prevent repeated attacks of similar 
nature. When no deviation from the normal standard exists 
aside from the condition dependent upon the acute attack, the 
general hygiene of the patient must be investigated. The daily 
use of the cold bath, preferably of the plunge bath, is essential; 
but if this for any reason is contra-indicated, the cold sponge 
bath may be substituted. The use of all-wool underwear and 
a regulation of the habits of life will ordinarily enable us to 
prevent successive attacks. 

Ordinarily the local treatment occupies the most promi- 
nent position in the mind of the physician; but it can not be 
too strongly urged that careful attention to the hygienic sur- 
roundings of the patient are of quite as much, and frequently 
of more, importance than the employment of the topical ap- 
plications. 



CHAPTER XVIII. 

TUBO-TYMPANIC CONGESTION. ACUTE TUBO-TYMPANITIS. 

TUBO-TYMPANIC CATARRH. 

In this condition, in addition to the changes already men- 
tioned as occurring in the Eustachian tube, there is present a 
congestion of the mucous membrane lining the middle ear, 
dependent upon the physical changes which the tubal occlu- 
sion causes rather than upon any actual inflammatory process 
within the tympanum. 

Etiology. — The same conditions which produce a tubal 
catarrh may cause the affection under consideration. The exact 
condition which results in any individual case depends both 
upon the activity of the exciting cause and upon conditions 
within the tympanum peculiar to the particular case. If the 
tympanic vessels are wanting in tone from some systemic con- 
dition, or have been in a state of engorgement for a considerable 
period from local causes, the sudden occlusion of the tubal 
lumen will effect certain changes within the middle ear recog- 
nizable upon physical examination, and active in the produc- 
tion of certain subjective symptoms. The exciting causes of 
the attack are usually the same as those of simple tubal catarrh, 
and their repetition here is unnecessary. 

Pathology. — We may find within the tympanum a simple 
engorgement of the vessels supplying the mucous membrane, 
leading to a general hyperemia of the inner tympanic wall 
and, to a lesser extent, of the drum membrane itself, this being 
most marked along the course of the vascular plexus. This 
congestion may result in two conditions — either one of hyper- 
secretion with the accumulation of mucus within the tympanic 
cavity, or in a simple serous exudation due to the tenuity of 
the vessel walls. This condition of the vessels is usually of con- 
stitutional origin and is not uncommon in those affected with 
a gouty diathesis or with chronic cardiac, hepatic, or renal dis- 
ease. In the membrana tympani this venous congestion is 

(3x7) 



3i8 



TUBO-TYMPANIC CONGESTION. 



evidenced by an increased amount of blood within the veins. 
As the vascular network is most rich in the upper and pos- 
terior segment close to the periphery and along the manubrium 
mallei, these localities show, upon inspection, deviations from 
the normal color. It is true that stasis is the first stage of any 
inflammation, but the disease under consideration does not usu- 
ally progress further than this first stage. The reduplications 
of mucous membrane in the upper part of the cavity may also 
be involved, the effused serum draining into the atrium or 
bulging the upper part of the membrane. Sometimes this 
bulging may be so great as to threaten spontaneous rupture, 
and it is then the duty of the surgeon to evacuate the fluid by 
incision before this rupture takes place. In cases of tubo-tym- 
panic congestion, the fluid thus evacuated will be found to be 
entirely free from bacteria. 

Symptomatology. — The symptoms already enumerated un- 
der tubal catarrh undergo slight modifications when the cavity 
of the middle ear is involved. Instead of the " stuffy " feeling 
so characteristic of Eustachian occlusion, these patients fre- 
quently complain of distinct pain in the ears, while the feeling 
of heaviness and numbness about the head is less marked. Pain 
is particularly well marked when the vault of the cavity is 
involved. The impairment of hearing is usually not as sudden, 
nor is it as pronounced as in simple occlusion of the tube. 
This may perhaps be explained upon the theory that the slight 
swelling of the membrana tympani renders its displacement 
by atmospheric pressure less easy, and consequently the ossi- 
cles are not crowded together as firmly as when no obstacle 
is offered to the displacement of the drum membrane. Tinni- 
tus is present, and may be distressing; it is prone to be influ- 
enced by the position of the patient, and is most complained of 
when the horizontal position is assumed, as this posture in- 
creases the vascular engorgement. When there is fluid within 
the middle ear the sufferer frequently complains of great varia- 
tions in hearing according to the position of the head. When 
sitting quietly he may be conscious of a slight impairment, but 
if the head is suddenly bent backward this impairment becomes 
marked, disappearing again when the erect position is resumed. 
The reason is that the effused fluid is capable of a certain 
amount of motion within the middle ear, and when the head is 
bent backward flows to the postero-inferior part of the cavity, 
covering the round and oval windows and interposing an ob- 



SYMPTOMATOLOGY— DIAGNOSIS. 



319 



stacle to the entrance of sound waves. Owing to the presence 
of fluid within the tympanum, vertigo is not an uncommon 
symptom in these cases. The vertiginous attacks are usually 
induced by such changes in the position of the head as will 
cause the fluid to flow back over the regions of the oval and 
round windows. With the head in the erect position, the 
patient will not suffer w 7 ith the vertigo. When, however, the 
head is thrown backward or to one side, the dizziness may be 
very severe. 

Another quite characteristic symptom is the occurrence of 
a bubbling or snapping sound when the patient blows the nose 
forcibly, or sometimes during the act of deglutition. During 
the performance of these acts the tubal obstruction momen- 
tarily becomes less complete, and the current of air entering the 
tympanum passes through the fluid and gives rise to the sound. 

Autophony is also frequently complained of, while sub- 
jective noises may vary considerably according to the posi- 
tion of the head, being usually more severe in the recumbent 
position. A condition of hyperesthesia of the auditory nerve 
may occur in these cases, causing certain sounds to be painful. 
The sounds producing a painful impression are high-pitched, 
but ordinarily not those of the highest pitch, since the occlu- 
sion of the niche of the round window by the fluid low r ers 
the upper tone limit of sound perception considerably. 

When the ear has been inflated by the patient himself, 
either accidentally or by design, the hearing immediately im- 
proves to a surprising degree, while the retrograde change may 
be equally sudden after the act of deglutition. 

Diagnosis. — A. Physical Examination. — The inspection of 
the parts by means of reflected light will reveal appearances 
which vary considerably in the different cases according to 
the actual conditions present. The distinctive feature, as con- 
trasted with a simple tubal stenosis, lies in the fact that the 
drum membrane or the internal tympanic wall shows evidences 
of circulatory changes, which are absent when the tube alone 
is affected. The position of the drum membrane is usually 
that of moderate retraction, the extent of this not being as 
great as when the tube alone is affected. The membrana tym- 
pani varies slightly from the normal color; instead of being 
pearly white, it is changed to either a dull white throughout, 
or it is of a light pinkish-white tinge. At the periphery and 
along the handle of the malleus the change of color is decidedly 



320 



TUBO-TYMPANIC CONGESTION. 



more marked and is of a dull-reddish hue. These changes in 
color along the manubrium and at the periphery do not indicate 
a true inflammatory condition, but a venous congestion sim- 
ply, with a consequent prominence of the veins forming the 
manubrial and peripheral plexus. This dull-reddish color is 
sometimes very prominent above the short process from the 
congestion within the tympanic vault and is indicative of the 
possibility of the process, progressing to suppuration. The 
pinkish tinge of the entire membrane which we sometimes ob- 
serve is due not to changes in the membrana tympani itself, 
but to congestion of the internal tympanic wall. The rays of 
light pass through the membrana tympani and illuminate the 
internal wall of the middle ear, which is in these cases consider- 
ably reddened. This colored background gives to the mem- 
brana tympani the pinkish tinge described, but the change in 
color depends upon congestion within the cavity rather than 
upon any changes within the membrana tympani itself aside 
from those already mentioned as occurring in the venous plexus 
of the membrane. 

The malleus handle appears foreshortened according to the 
degree of collapse, but seldom to the extent seen in simple 
Eustachian occlusion ; the anterior and posterior folds are more 
prominent than normal; from stasis the membrane may appear 
thicker than normal, and may partially lose its lustre. On 
account of the displacement, the light reflex is changed both 
in position and shape, and may be multiple. These changes 
are recognized ordinarily when no effusion has taken place 
within the tympanic cavity. If, owing to the abnormal full- 
ness of the vessels, a certain amount of transudation has taken 
place within the tympanum, the degree of depression is not 
apt to be as marked. Instead of this, a close inspection will re- 
veal the membrana tympani, presenting in its inferior segment 
a slightly yellowish color, the lustre of the membrane being 
diminished, while the density is increased. This dull look is 
wanting in the upper part of the membrane, the illuminating 
rays penetrating it and revealing more or less distinctly the 
condition of the inner tympanic wall ; and if the membrana tym- 
pani is thin, frequently enabling the observer to recognize the 
long process of the incus on the posterior crus of the stapes 
(Fig. 95). The appearance is due to a collection of fluid in the 
lower part of the tympanic cavity, the result of serous transu- 
dation. Xot infrequently we observe the line of demarcation 



DIAGNOSIS— PHYSICAL EXAMINATION. 



321 



between the upper and lower areas as sharp and distinct, ap- 
pearing as a fine line which traverses the membrana tympani 
transversely (see colored plates). This line marks the level of 
the fluid in the tympanic cavity, and may be mistaken for a 
hair stretching across the surface of the drum membrane. By 
tilting the head of the patient forward or backward, it is often 
possible to observe changes in the direction of the fluid line. 
If the patient practices auto-inflation, the current of air upon 
entering the tympanic cavity will bubble up through the con- 
tained fluid, and upon inspection these bubbles are visible (Fig. 
96); they change their position when the patient swallows or 





\ 






Fig. 95. — Moderate retraction of mem- Fig. 96. — Posterior segment of mem- 
brana tympani. Incudo-stapedial ar- brana tympani bulged by fluid in the 
ticulation visible in upper posterior tympanum. Bubbles of air in the fluid 
quadrant. are visible through the membrane. 

forces more air into the tympanic cavity. Naturally their pres- 
ence is an unquestionable evidence of fluid. In cases where 
the drum membrane has been thickened from preceding inflam- 
mation it may be so dense as to prevent the recognition of these 
air bubbles upon ocular inspection. In such instances several 
bright points of light are often seen upon the surface of the 
membrane below the level of the fluid. These multiple reflexes 
are indicative of the presence of fluid, although they must not 
be relied upon as absolutely characteristic of this condition. 
Inflation with the catheter or by Politzer's method will reveal, 
through the diagnosis tube, the characteristic bubbling as soon 
as the air enters the middle ear. When serum alone is present 
the rales produced by the bursting of the bubbles will be sharp 
and high-pitched; when a certain amount of mucus is mixed 
with the serum, the sound will be of lower pitch and of less 
intensity and the explosive sounds will follow each other at less 
frequent intervals. The absense of rales upon auscultation can 
not be taken as a positive evidence that no fluid is present in 
the middle ear. A small amount of effusion may lie entirely 
out of the air current and give no sign of its presence. Again, 
the fluid may be incapsulated in a fold of the mucous membrane, 
and thus be unaffected by the operation of inflation. 



322 



TUBO-TYMPANIC CONGESTION. 



B. Functional Examination. — Upon examining the patient 
with reference to the power of audition we shall find dimin- 
ished air conduction, both for sharp sounds — such as the watch 
and acoumeter — and for the conversational voice and whispered 
speech, the defect for the vocal sounds being relatively more 
marked than for isolated sharp sounds. The tuning fork will 
show an elevation of the lower tone limit, while the Galton 
whistle indicates a reduction of the upper tone limit. This 
latter will be more marked when fluid is present and occupies 
such a position as to cover the round and oval windows. The 
vibrating tuning fork, placed upon the forehead, is usually later- 
alized to the more affected side in cases of bilateral disease, or 
toward the affected side when only one ear is involved. Abso- 
lute bone conduction for a fork of two hundred and fifty-six 
or five hundred and twelve double vibrations per second is usu- 
ally increased, although sometimes it may be slightly less than 
normal. While this latter condition indicates the involvement 
of the perceptive apparatus, the labyrinthine lesion depends 
upon the process within the middle ear, and will disappear when 
the tympanic condition becomes normal. The presence of fluid 
in the middle ear may modify the results of the functional tests, 
and render an exact diagnosis of the condition of the perceptive 
apparatus impossible until it has been removed by therapeu- 
tic or surgical measures and the conducting mechanism has 
been restored as nearly as possible to its normal condition. 

Prognosis. — In many of these cases, especially in children, 
the parts return to a completely normal condition without 
treatment. In adults, while spontaneous recovery occurs in 
a certain proportion of instances, it is probable that the func- 
tion of the organ is not completely restored. Aside from spon- 
taneous resolution, we may have developed, as a result of this 
process, a chronic otitis media, the persistent congestion of 
the parts ultimately resulting in an inflammatory process of 
the chronic type. This may result either in an hypertrophy 
of the mucous membrane lining the cavity, the reduplications 
increasing in number and in density, or occasionally we have 
developed a true hyperplastic inflammation, in which the con- 
nective-tissue framework of the lining membrane of the middle 
ear becomes firm, the interfibrillary substance being absorbed, 
and a sclerotic condition is the result. This process is usually 
more pronounced in the region of the oval and round windows 
than elsewhere. The membrane of the Eustachian tube may 



TREATMENT— INFLATION. 323 

undergo similar changes. When the hypertrophic changes 
occur within the tympanum the Eustachian tube is also affected, 
its calibre being so narrowed that ventilation of the tympanum 
is interfered with. In the hyperplastic or sclerotic inflamma- 
tion the result is to increase its calibre rather than to diminish 
it. In those cases where the circulatory system is impaired 
from diathetic causes, the effusion in the tympanic cavity may 
increase in amount when the mucous membrane of the upper 
air passages is congested as the result of exposure to cold or 
of some disturbance of the prima? vise, diminishing in quan- 
tity or disappearing when the patient is in a fairly normal con- 
dition. 

Treatment. — In the acute stage the measures already men- 
tioned under the treatment of tubal catarrh are to be adopted. 
Proper attention to clothing and hygienic surroundings and 
the treatment of the upper air passages, surgically or other- 
wise, is of the greatest importance in preventing recurrent 
attacks. 

In addition to this we have to deal with the congestion 
within the tympanum itself, and when effusion is present our 
treatment must be of such character as to produce either its 
absorption or its exit by mechanical means. For the relief of 
the venous engorgement local bloodletting stands pre-eminent. 
The abstraction of from two to four ounces of blood from the 
region immediately in front of the tragus is frequently followed 
by a complete cessation of the unpleasant symptoms and resto- 
ration of function. When seen early, this method may prevent 
the effusion of fluid into the middle ear. Next we should try 
to prevent this transudation by restoring the intratympanic 
pressure as nearly as possible to its normal standard. This is 
to be effected by inflation of the middle ear, either by the Polit- 
zer method or by the use of the Eustachian catheter. Authori- 
ties vary considerably as to the propriety of using the air 
douche in acute congestion of the tympanum. To my mind, 
there is no question but that inflation is beneficial in a very 
large proportion of these cases, and frequently shortens the 
duration of the disease, preventing transudation of serum by 
supporting the intratympanic vessels. The relief to the sub- 
jective symptoms is also very marked, and in no instance have 
I seen the condition aggravated by the operation, even when 
relief did not follow. After the effusion of serum has taken 
place, local bloodletting is ordinarily useless unless actual pain 



324 TUBO-TYMPANIC CONGESTION. 

is present, and we have reason to fear that the process may 
become inflammatory. 

After effusion has taken place our efforts should be directed 
toward its removal. Two ways are available : either evacuation 
by incision through the drum membrane, or removal through 
the Eustachian tube. The objection to early incision of the 
membrana tympani is the supposed tendency to recurrence 
when the fluid is evacuated in this manner. Unless the transu- 
dation is considerable in amount and causes much discomfort, 
it is well to attempt its .absorption, reserving incision of the 
drum membrane for persistent cases only. The prime factor 
influencing the absorption of the fluid is a patulous condition 
of the Eustachian tube, thus relieving the venous turgescence 
and permitting the passage of the effusion into the lymphatics. 
The restoration of the tube to a patulous condition is effected 
by the use of the catheter, the bougie, the application of as- 
tringents to the orifice of the tube, or inflation with medicated 
vapors. These measures have been detailed under tubal 
catarrh. When the condition has existed for a considerable 
time the mucous membrane of the middle ear may not readily 
take up the fluid. Here inflation with any medicated vapor 
which will stimulate the lining membrane may accomplish the 
desired object. For this purpose we may use menthol or cam- 
phor in the proportion of one drachm to an ounce of alcohol, 
the vapor of the oil of eucalyptus in full strength, or even 
alcohol vapor alone. It is best, when the fluid is not too viscid, 
to evacuate a certain amount of it through the Eustachian tube 
by means of the air douche. To do this the head should be 
inclined forward and toward the unaffected side during the per- 
formance of the operation, and occasional attempts at degluti- 
tion should be made, as this act renders the tube more patulous 
and permits the fluid to be displaced more easily. An effusion 
of this character should yield to treatment in not less than four- 
teen days, the air douche being administered at first daily, and, 
as the condition improves, at longer intervals. If a decided 
impression has not been made upon the fluid at the end of this 
time it is unwise to delay longer, and the membrana tympani 
should be incised. The same plan should be adopted even at' 
an earlier period if the patient can not be kept under observa- 
tion sufficiently long to insure a complete restoration by the 
milder measures already indicated. Considerable difference of 
opinion exists as to the precise location and the extent of in- 



TREATMENT— INCISION. 



325 



cision through the drum membrane. To my mind the question 
should be decided on general surgical principles. The object 
sought ic perfect drainage and a rapid and perfect restoration 
of the parts to their normal condition. These ends can be 
attained only by a free and extensive incision which will evacu- 
ate all the fluid and leave the parts in a condition favorable to 
immediate union throughout the entire line of section. In 
order that the drainage may be perfect, the lowest point of the 
opening must lie near the inferior pole of the drum membrane. 
Since the upper and posterior part of the cavity is the most 
capacious, an effusion sufficient in amount to demand evacua- 
tion usually causes a bulging of the drum membrane in this 
locality. I prefer, therefore, to insert an exceedingly sharp 
but delicate knife close to the periphery of the membrana at 
a point opposite the short process; the knife is then carried 
downward close to the periphery to the lowest point of attach- 
ment of the membrana tympani. The section lies entirely 
within the clear membrane, and should not wound the carti- 
laginous ring. When considerable congestion is present it is 
advisable to secure local depletion by carrying the knife suffi- 
ciently inward to make it impinge upon the internal tympanic 
wall so as to divide the soft parts which cover it, throughout 
the entire extent of the 
incision through the drum 
membrane. If the parts 
above the short process 
are intensely congested 
the incision is to be ex- 
tended upward so as to 
enter the vault and de- 
plete the engorged tis- 
sues. In these cases it is 
usual to incise from below 
upward (Fig. 97). A few 
vigorous efforts at infla- 
tion by means of the 
Politzer method clears 
the cavity completely of 
fluid, the divided parts fall 

readily into place, approximation being practically perfect, and 
it is not unusual to find complete union at the end of thirty-six 
hours. The only possible untoward result following this pro- 




Fig. 97. — Method of incising membrana tym- 
pani to evacuate fluid in the atrium (natural 
size). 



326 TUBO-TYMPANIC CONGESTION. 

cedure is accidental infection at the time of the operation. To 
avoid this the canal should be first syringed with a solution of 
bichloride of mercury (i to 8,000), while the instruments em- 
ployed should be sterilized by boiling. After the fluid has 
been evacuated the canal should be closed by a plug of aseptic 
cotton and the patient should on no condition interfere with it. 
Carried out in this manner, there is absolutely no danger in 
adopting this method of treatment for an effusion of any kind 
within the tympanic cavity. In nervous patients it is well to 
perform the operation under nitrous oxide anaesthesia. 

Nothing has been said concerning the administration of in- 
ternal remedies. I have little faith in the beneficial action of 
any drug for the correction of the condition under considera- 
tion. As a prophylactic measure it is well, upon the disap- 
pearance of the attack, to guard against recurrence by the ex- 
hibition of drugs supposed to be particularly efficient in over- 
coming a lymphatic diathesis. This is especially true in the 
case of children. The administration of the iodide of iron in 
doses of four to eight grains three times daily, together with 
hypophosphites, will do much in the direction of causing a 
spontaneous disappearance of the deposits of lymphatic tissue 
in the naso-pharynx and pharynx. Often after surgical inter- 
ference, it is well to employ these remedial agents for a period 
of a month or six weeks to insure the permanency of the re- 
sult. Where the condition depends upon a disturbance of the 
vascular apparatus, as in arterio-capillary sclerosis, or upon a 
renal lesion, the proper treatment of the general disease may 
do much to diminish the local process. The application of 
astringent remedies to the tympanic cavity, either through 
the Eustachian tube or through an artificial opening in the 
drum membrane, is not, I think, indicated in this condition, 
since we are dealing not with an inflammation, but with an 
obstruction to the venous flow. 



CHAPTER XIX. 

ACUTE CATARRHAL OTITIS MEDIA. 

This term is applied to an actual inflammatory condition 
within the middle ear, resulting in an increase in the normal 
secretion. In this way it differs from the process just described. 
Why in one patient we should have a simple congestion of the 
tympanic lining, and in another an acute inflammatory process, 
the factors of causation being similar in the two cases, it is 
impossible to state. It seems that the difference must depend 
somewhat upon the power possessed by the individual to resist 
the invasion of pathogenic bacteria and also upon the virulence 
or degree of infection in the individual case. It is certain that 
venous stasis plays a part in the causation, as in this condition 
any membrane is particularly susceptible to the absorption of 
bacteria. The infection, then, of an individual in perfect health 
might result in the first stage of inflammation simply or an 
obstruction to the venous flow with possible effusion of serum 
from mechanical causes alone. In an individual less robust the 
infective process would be carried one step farther, and we 
should have, following the stage of congestion, an actual inflam- 
matory process developed. Here again comes the question as 
to why in certain instances this inflammatory process results in 
the formation of mucous secretion, and in others in the forma- 
tion of pus. We have in the structure of the middle ear a suffi- 
ciently clear explanation of this, I think. Remembering that 
the upper part of the cavity contains a large amount of con- 
nective tissue, we should expect infection in this region to be 
followed by an inflammation of the cellular type, while infection 
of the lower portion of the cavity would result in a simple 
catarrhal inflammation of the lining mucous membrane. Clin- 
ical experience bears out this theory. It is this last-named proc- 
ess that occupies our attention at present. 

^Etiology. — An acute catarrhal otitis may complicate mea- 
sles or a cold in the head, or may be caused by the introduction 

(327) 



328 ACUTE CATARRHAL OTITIS MEDIA. 

of fluids into the middle ear through the Eustachian tube while 
bathing:, or through the use of the nasal douche. Violent 
efforts at clearing the nostrils may occasionally cause the affec- 
tion in the same manner. Any abnormal condition of the upper 
air passages, particularly the presence of an enlarged pharyn- 
geal tonsil, predisposes to this disease. Exposure to cold or 
wet may bring on an attack without any other symptoms refer- 
able to the upper air tract being present. Traumatic rupture 
of the membrana tympani may lead to an infection of the atrium 
and a simple inflammation of its lining membrane, although in 
most cases of these instances the inflammation is purulent in 
character. 

Pathology. — The pathological changes have been described 
in what has already gone before. The inflammation is con- 
fined to the superficial layer of the lining membrane of the tym- 
panum, the basement membrane escaping. Most frequently 
only the lower part of the tympanic cavity is involved. The 
reduplications lying within the vault are congested and swollen, 
but the process does not go farther than this. As the result 
of the inflammation the action of the mucous glands is stimu- 
lated, and their secretion, mixed with the transuded serum, fills 
the tympanic cavity with a turbid fluid, rather thick in con- 
sistence and containing much mucin and holding in suspension 
desquamated epithelial cells. The changes involve the mucous 
layer of the membrana tympani. which becomes swollen and, 
by exfoliation of its superficial cells, leaA'es the fibrous layer ex- 
posed: this becomes infiltrated also, and from the pressure of 
the accumulated secretion may give way at one point, per- 
mitting the pent-up fluid to flow into the canal. Spontaneous 
perforation in these cases probably depends as much upon the 
increased pressure as upon the actual inflammatory process 
involving the deeper layers of the drum membrane. The Eu- 
stachian tube, while partaking of these pathological changes 
to a certain degree, is not involved to the same extent as in a 
simple salpingitis, the activity being more directed toward the 
lining membrane of the middle ear. 

In recent years much attention has been paid to the deter- 
mination of the various forms of bacteria which may be present 
in aural discharge. In the disease under consideration, the 
micro-organisms will vary according to the predisposing cause 
of the aural affection. The severity of the attack will also de- 
pend largely upon the character of the micro-organism which 



PATHOLOGY— SYMPTOMS IN ADULTS. 329 

has induced the disease. In the milder cases we find a staphy- 
lococcus or diplococcus infection. In the severer cases, we 
have a streptococcus infection. In certain cases, complicating 
epidemic influenza, the specific influenza bacillus has been 
found. 

Symptomatology. — The symptoms vary considerably, ac- 
cording to the age of the patient. For convenience we will 
consider the disease first as affecting adults, and later as 
affecting children. 

A. In Adults. — The early symptoms may be so slight as to 
pass unnoticed. They consist in a feeling of fullness and stuffi- 
ness in the ear, dependent upon the occlusion of the Eustachian 
canal. This sensation is soon followed by pain in the ear re- 
ferred to the tympanic cavity, and of steadily increasing sever- 
ity. The degree of pain is ordinarily sufficiently acute to pre- 
vent sleep, provided the attack occurs at night. The pain is 
usually distinctly localized, and seldom partakes of the diffuse 
character found in inflammation of the external meatus, while 
its severity enables it to be distinguished from that due to 
closure of the Eustachian tube. The pain is usually most severe 
upon lying down, owing to the determination of blood to the 
head when this position is assumed. Subjective noises of high- 
pitched character manifest themselves quite early, but are not 
complained of, on account of the severity of the pain. Impair- 
ment of hearing is at first slight, but steadily increases, and may 
reach an exceptionally high degree. When the stage of hyper- 
secretion is reached the pain subsides gradually, being replaced 
by a feeling of fullness or heaviness in the side of the head. 
Each act of deglutition is painful, and the patient is conscious 
at these times of the entrance of air into the tympanum, its 
passage through the fluid producing bubbling sounds, while 
the movement which it causes in the intratyrnpanic structures 
is attended by lancinating pain on account of the swollen con- 
dition. The body temperature is seldom elevated, but from the 
severity of the pain considerable prostration may follow. At 
any period varying from twelve to forty-eight hours spontane- 
ous rupture of the membrana tympani may take place, as evi- 
denced by the appearance of a sero-mucous discharge from the 
external auditory meatus, and an abrupt cessation of the pain. 
In many cases rupture does not take place, and the disease, 
having run its course, leaves within the tympanic cavity a col- 
lection of sero-mucus, which then produces the characteristic 
23 



330 



ACUTE CATARRHAL OTITIS MEDIA. 



symptoms of an intratympanic effusion. If the drum membrane 
is exceedingly dense and does not yield to the pressure of the 
fluid, the vault of the tympanum may become involved secon- 
darily, and a purulent inflammation supervene. In still other 
instances, where no spontaneous outlet is effected, the lining 
membrane of the mastoid cells becomes involved. The patient 
complains of severe pain behind the ear, gradually spreading 
to the side of the head. This involvement is usually associated 
with an elevation in body temperature and an increase in the 
severity of all the symptoms. 

The discharge may cease spontaneously at the end of a few 
hours or days. It may continue as a sero-mucous discharge, 
or by exposure to the air it may become infected, its character 
then changing to a purulent secretion. When this occurs, the 
infection may spread to the middle ear, involving the structures 
situated within the vault, and may then follow the ordinary 
course of a chronic purulent inflammation of the middle ear. 
In other cases the discharge of the fluid is followed by a com- 
plete cessation of all symptoms, the opening of the membrana 
tympani closing spontaneously and the parts returning to their 
normal condition. 

B. In Children. — In very young children the symptoms 
characteristic of an acute catarrhal inflammation of the mid- 
dle ear may be of so severe a type as to incline one to the 
opinion that the child is suffering from a much graver disease. 
The attack usually comes on at night. The infant at first 
tosses about in bed and throws the arms upward over the head, 
usually toward the affected side, although this is not invariable. 
After a short period of disturbed sleep the child wakens and 
gives evidence of intense suffering. The temperature is fre- 
quently exceedingly high, and may reach 106 , but usually 
varies from 102 to 104 . From the very fact that the ear is 
usually the organ least suspected, we may remain in complete 
ignorance of the cause of this rise in temperature until, after 
several hours, a sero-mucous discharge appears in the meatus. 
This is usually accompanied by a cessation of all symptoms, the 
child dropping off to sleep and the temperature gradually fall- 
ing. In certain cases the attack may be ushered in by repeated 
convulsions and by vomiting, simulating very closely an at- 
tack of meningitis. With the appearance of discharge in the 
ear pain usually ceases, and in many cases the temperature be- 
comes perfectly normal. This is not the invariable rule, how- 



SYMPTOMATOLOGY— IN CHILDREN. 331 

ever, even though drainage is free. The drum membrane of a 
child is exceedingly thin and yields easily to the outward pres- 
sure of the fluid, rupturing before the inflammation within the 
tympanic cavity has ceased. An elevation of the temperature, 
therefore, may continue for a few days after perfectly free drain- 
age is secured. When this is the case the temperature is apt 
to be either remittent or intermittent, the elevation in the after- 
noon reaching 103 or 104 in many cases. 

The character of the discharge both in adults and children 
varies acording to the period of the disease. During the first 
few days the fluid is large in amount, turbid from the mixture 
of epithelial cells, and rather viscid in consistence from the 
presence of mucin. The viscidity of the discharge offers an 
obstruction to its free exit through the small opening in the 
drum membrane and obstructive symptoms may occur. As a 
rule the discharge is much more profuse in children than in 
adults and contains a greater number of epithelial cells. When 
the case progresses favorably the secretion gradually dimin- 
ishes in amount, becomes thinner and more watery, and finally 
disappears entirely. If proper attention is not paid to clean- 
liness the fluid may become infected in the auditory canal, the 
infection may spread to the tympanic cavity, and a purulent 
otitis media supervene from inoculation of the connective-tis- 
sue structures in the tympanic vault. This accident need never 
happen if proper attention is paid to cleanliness. The presence 
of the secretion in the meatus tends to soften and remove the 
epithelial matter, thus leaving a denuded surface, through 
which infection may take place and localized or diffuse otitis 
externa follow. 

After the appearance of the discharge the constitutional 
symptoms may again become severe if the opening through 
the drum membrane becomes occluded either by thick mucus 
or as the result of the reparative process; especially is this true 
when a case progresses rapidly toward recovery and an acute 
naso-pharyngitis occurs as the result of exposure to cold. From 
this cause the inflammatory process within the middle ear be- 
comes augmented and a sudden increase in the amount of secre- 
tion takes place. The opening through the drum membrane 
is not of sufficient size to permit of free drainage, and the 
symptoms already described in the earlier part of the chapter 
are repeated. A relapse of this character is always to be feared, 
since there is danger of secondary inflammation of the mastoid 



332 



ACUTE CATARRHAL OTITIS MEDIA. 



cells. Occlusion of the opening in the membrana tympani, 
even for a short time, may also result in mastoid involvement 
by any fresh access of inflammatory process. 

The impairment of hearing and the subjective noises usu- 
ally diminish after the pressure within the tympanum is re- 
lieved by the passage of the contained fluid into the auditor}* 
meatus. Xecrosis of the osseous tympanic wall or of the os- 
sicula themselves does not take place in simple catarrhal otitis, 
although the condition is frequent in the purulent variety. 
These sequelae will be considered under a chapter on purulent 
otitis media. 

Diagnosis. — A. Physical Examination. — An inspection of 
the canal and membrana tympani in the early stages will re- 
veal a distinctly hyperaemic condition of the drum membrane, 
most marked in the region of the manubrium, the redness 
shading off gradually into the normal color of the part. The 
structures above the short process — that is, in Shrapnell's mem- 
brane — may also present a reddish color quite early in the dis- 
ease, since the blood vessels of the membrana tympani are 
richly distributed in this region and venous congestion may 
be marked. The hyperaemia is distinguishable from the vascu- 
lar congestion present in tubo-tympanitis from the fact that the 
vessels themselves do not stand out prominently, but the red- 
ness is diffuse, merging gradually into the normal pearly white 
color of the membrana tympani, while in tubo-tympanitis the 
outline of the vessels is distinctly marked and there is a line of 
demarcation between the hyperaemic areas which are identical 
with the normal vascular plexus and the remainder of the mem- 
brane. The position of the drum membrane may be normal, 
although quite frequently it is moderately depressed; exten- 
sive collapse of the part upon the internal tympanic wall does 
not occur as a rule. At a later period the entire membrana 
tympani, particularly the membrana vibrans, is uniformly red- 
dened; the lustre is wanting; the landmarks may be obscured 
on account of oedema; the short process of the malleus, how- 
ever, is seldom completely hidden, even in severe cases, if care- 
ful search is made for it. At this period effusion has usually 
taken place, the result being to force the drum membrane out- 
ward into the canal. The displacement is usually most marked 
in the upper and posterior part (Fig. 98) : in children, and in 
adults where the membrana tympani is more obliquely placed 
than usual, the membrana seems to be continuous with the 




DIAGNOSIS— PHYSICAL EXAMINATION. 333 

postero-superior wall of the meatus, narrowing the fundus of 
the auditory canal, this region being converted into a small 
quadrangular area of not more than one quarter the normal size 
(Fig. 87). Such a narrowing is quite as char- 
acteristic of bulging of the drum membrane as 
a distinct globular mass filling the fundus of 
the canal. A point to be remembered in this 
connection is that the entire membrana tym- 
pani bulges as a whole, the change in position FlG 9 8.— Moderate 
not being limited to the membrana flaccida. bulging of entire 

r^, . . . , 11 J- ,• membrana tym- 

Ihis is of considerable diagnostic importance pan i. 
when we remember that inflammations of a 
purulent character usually involve the upper portion of the 
cavity first, and the presence of fluid causes a protrusion of 
the membrana tympani above the short process of the malleus. 
More attention will be paid to this in a later chapter. 

After the discharge has made its appearance, an inspection 
of the ear will reveal the canal filled with sero-mucous fluid. 
Upon removing this, the surface of the drum membrane will 
be seen covered with a dense white lustreless coating. This 
is due to a necrosis of the superficial epithelial layer, and may 
be easily removed by means of the cotton pledget, when the 
external surface of the membrana tympani will be seen to be 
red and swollen. The point of rupture should be searched for 
carefully, but where the canal is swollen it is sometimes difficult 
to locate it exactly. Usually it is found in the inferior seg- 
ment, either just below the manubrium or in the anterior portion 
close to the periphery of the drum membrane. When exam- 
ined immediately after rupture has taken place, the discharge 
pours out so rapidly that it is difficult to determine exactly the 
location of the opening. Nor is this of importance, provided we 
ascertain that it is of sufficient size to admit of free drainage. 
The presence of a muco-serous discharge in the canal is suffi- 
cient evidence that perforation has taken place. The use of 
the Politzer air bag or of the Eustachian catheter will, when 
the ear is inflated, afford us a certain evidence of this from the 
sharp, high-pitched perforation whistle. This sound is modi- 
fied by the passage of the current through the fluid. Before 
perforation has taken place inflation gives simply the sounds 
characteristic of fluid within the tympanum. 

In children we are not uncommonly called upon for an 
opinion immediately following an attack of " earache.'' From 



334 



ACUTE CATARRHAL OTITIS MEDIA. 



the history, we learn that the morning following an attack a 
slight amount of moisture was present upon the pillow, and 
that the margin of the orifice of the meatus was coated with 
a yellowish incrustation. At the time of our examination no 
discharge is present in the canal, the only symptom from which 
the child is suffering being an elevated temperature. Inspec- 
tion reveals congestion of the entire membrana, while at one 
point we are able to make out a localized hemorrhagic deposit. 
The signification of this appearance is that the attack was of 
only slight severity, and that spontaneous rupture occurred. 
The pressure was relieved by this means of exit to the effusion, 
and the minute opening has already closed. Our efforts here 
are confined to the prevention of subsequent attacks, as the 
immediate condition is undergoing spontaneous resolution. 

B. Functional Examination. — Ordinarily the pain is so great 
in these cases that the functional examination is seldom made. 
We shall find, however, that the tuning fork placed in the 
median line of the skull will be referred to the affected side; 
air conduction for the lower portion of the scale will be want- 
ing or much diminished. The upper tone limit may be nor- 
mal or slightly reduced, and absolute bone conduction will be 
increased. The power of audition, both for speech and for 
sharp sounds, will also be much reduced. 

Prognosis. — These cases terminate favorably, as a rule, 
often without treatment. Purulent otitis media and involve- 
ment of the mastoid cells occasionally occur. The latter con- 
dition may supervene whether perforation takes place or not. 

If perforation does not take place, the case may fail to un- 
dergo complete resolution, and a certain amount of fluid may 
remain in the tympanum, causing impaired hearing and a per- 
sistence of subjective noises. If the fluid is absorbed, the mu- 
cous membrane may fail to return to its normal condition and 
become the seat of a chronic inflammatory process either of an 
hypertrophic or proliferative type. From the long-continued 
presence of fluid within the tympanum the drum membrane 
may become relaxed, and after the fluid has disappeared this 
change of tension may give rise to subjective noise, and to an 
impairment of audition from the ease with which it is depressed 
when the atmospheric pressure within the middle ear is 
diminished. 

When perforation has taken place, the opening may close 
spontaneously; or it may persist, leaving the internal wall of the 



PROGNOSIS. 335 

tympanum exposed; or the ligamentous structures within the 
middle ear may undergo cicatricial contraction, displacing the 
parts and interfering seriously with their function. This lat- 
ter condition usually results when the inflammation becomes 
purulent in character. In a certain proportion of cases a sim- 
ple catarrhal inflammation of the lower portion of the tym- 
panum becomes purulent from infection through the Eusta- 
chian canal before the perforation takes place. This is particu- 
larly prone to occur when the process is active and the parts 
within the tympanic vault are excessively hypersemic; the dis- 
ease then follows the same course as acute purulent otitis. 

The prognosis of the case is somewhat influenced by the 
bacteriological investigation of the discharge. In cases of 
simple catarrhal inflammation, involving the lower portion 
of the tympanic cavity, any micro-organism may act as the 
exciting cause of the disease. In those cases where the inflam- 
mation is confined to the lower portion of the middle ear, the 
micro-organism is one of low vitality. Those cases where the 
disease extends upward, involving the connective-tissue struc- 
tures from the tympanic vault, however, represent a type of 
infection of exceeding virulence. In order that the surgeon 
may judge somewhat as to the further progress of the case, it is 
always wise, when spontaneous rupture of the drum membrane 
occurs, to make a bacteriological examination of the discharge, 
and in cases where the pain is severe and where rupture does not 
take place at an early stage, it is even wise to incise the drum 
membrane, and examine the secretion evacuated by incision in 
order to gain some idea of the character of the infection. In the 
mild cases we usually find a staphylococcus infection present, or 
one of the less active forms of bacteria. In those cases where 
the clinical history shows the disease has been very active, where 
the pain has been severe, the temperature high, and the local 
manifestations have appeared within the course of a few hours, 
we frequently find that we have to deal with a streptococcus 
infection, or we may have one of the various forms of diplococ- 
cus infection, such as diplococcus pneumoniae. Where the in- 
fection is due to streptococcus or pneumococcus, a rather 
guarded prognosis as to the involvement of the adjacent struc- 
tures should be given. In cases of staphylococcus infection, 
the patient may be reasonably assured that the disease will ter- 
minate favorably, without involvement of the adjacent bony 
parts. 



336 ACUTE CATARRHAL OTITIS MEDIA. 

Serious inflammation of the intracranial structures probably 
never occurs when the disease is of a catarrhal type. In chil- 
dren, where the tympanic roof is exceedingly thin, it is not 
improbable that meninges in the immediate neighborhood are 
congested; but the process stops here, and a true meningitis is 
not developed. 

Treatment. — The first indication is the relief of pain. The 
patient should be put to bed, a saline cathartic administered, 
and complete relief from pain secured by the administration 
of an opiate. In adults a hypodermic injection of ten to twelve 
minims of A Iagendie's solution is the most convenient form of 
administration, while in children the camphorated tincture of 
opium is to be preferred. It can not be too strongly insisted 
upon that complete relief from pain should be secured for 
a period of at least five or six hours, during which time at- 
tempts should be made to abort the inflammation. This end 
is attained more certainly by local bloodletting than by any 
other measure. From two to four ounces of blood should be 
drawn by means of the artificial leech from immediately in front 
of the tragus, or two natural leeches may be applied in this loca- 
tion if the surgeon prefers to make use of them. 

The application of dry heat is certainly of value in reliev- 
ing pain, and does not interfere with measures directed toward 
aborting the attack. The most convenient means of applying- 
this is by means of a hot-water bag or Japanese pocket stove. 
Moist heat is objectionable, since it favors venous congestion, 
softens the tissues, and hastens local necrosis, rather aiding the 
development of the process we desire to abort. Theoretically 
cold applications would be of benefit; but the presence of any 
fluid of low temperature within the external auditor}- canal is 
painful under ordinary circumstances, and when the parts are 
acutely inflamed it is unbearable. 

It is decidedly unwise to instill any oily solutions into the 
canal for the relief of pain. This practice is very common, 
and only serves to obscure the parts when an examination is 
made, and possesses absolutely no therapeutic value. A so- 
lution of carbolic acid in glycerin, in the proportion of one 
to twenty, is sometimes of sen-ice, and there is no objection 
to its use. The same may be said of aqueous solutions of mor- 
phine, atropine, and cocaine. The relief obtained is usually 
temporary, and we simply prolong the duration of the disease 
bv their use. 



TREATMENT— INCISION. 



337 



Failing to abort the attack, and the pain continuing, we 
should not delay incision of the membrana tympani. It is of 
great importance, I believe, to perform this operation early, 
and not to wait until it is evident that spontaneous rupture 
will take place unless the fluid is evacuated artificially. The 
local depletion secured by the operation is of great value, while 
the relief to pain is usually immediate and permanent. If, then, 
at the end of twelve hours, the patient still complains of pain, 
the membrana tympani should be freely incised. When dis- 
tinctly bulging, the centre of the incision should be over the 
most prominent point; but in the absence of any particular 
sign to guide us, the knife should be entered close to the 
periphery of the membrana tympani, just below the posterior 
fold, and the membrana completely divided by a curved incision 
downward to its inferior pole, the incision lying entirely within 
the clear membrane and parallel to its line of insertion. It is 
also wise to incise at the same time the membrane of the inter- 
nal tympanic wall to secure additional depletion. This pro- 
cedure is of value even when but a small amount of transuda- 
tion has occurred. The operator should be exceedingly careful 
to use a knife which will pass through the membrane by its own 
weight, under which circumstances scarcely any pain is expe- 
rienced. Attempts to anaesthetize the membrana tympani by a 
strong solution of cocaine scarcely diminish the pain instant 
upon the operation. In infants chloroform is the ideal anaes- 
thetic, while in older children and in adults nitrous oxide should 
be used. 

Before operating the field should be rendered aseptic in 
the manner already described in the consideration of the similar 
operation in the chapter on tubo-tympanitis. After the mem- 
brana has been divided, irrigation with a warm antiseptic solu- 
tion relieves whatever pain may be present, and aids the divided 
vessels to return to their normal calibre. If section is per- 
formed early we may cut short the attack, the incision closing 
at the end of thirty-six or forty-eight hours, and the symptoms 
subsiding completely. When the operation has been post- 
poned until the process is well advanced, the discharge ordi- 
narily continues for a period of two to ten days, and may be 
quite profuse at first. During the period of discharge which 
may follow either spontaneous rupture or evacuation by sur- 
gical interference, the canal must be kept thoroughly cleansed. 
This end is best attained by the frequent use of the ear syringe 



338 ACUTE CATARRHAL OTITIS MEDIA. 

in the hands of an attendant. The cleansing fluid may be 
either water which has been boiled and allowed to cool until it 
can be tolerated by the patient, or a mild antiseptic solution 
may be used. The frequency with which irrigation may be per- 
formed will depend upon the amount of discharge. At first 
the ear may require cleansing six times daily; the interval is 
gradually prolonged as the discharge becomes less viscid and 
diminished in quantity. It is important that these cases should 
be seen at first daily by the surgeon himself, at which time any 
fluid within the tympanic cavity should be thoroughly evacu- 
ated by the use of the air douche, the parts being afterward 
dried with absorbent cotton. It has been my practice, where 
I have been able to observe the case daily, to insufflate a small 
amount of boric acid into the canal after cleansing, thus se- 
curing a permanently aseptic condition of the parts, and guard- 
ing against carelessness on the part of the attendant, which 
might result in infection. Under no condition is a large amount 
of powder to be introduced into the ear, and unless the ear is 
inspected daily it should be a cardinal rule that no powders 
are to be used. When the discharge has nearly ceased, and is 
so small in amount that it does not appear in the external mea- 
tus when the ear is left undisturbed for twenty-four hours, 
more prompt recovery takes place if fluid applications are dis- 
continued entirely, the discharge being removed by absorbent 
cotton, after which a small amount of boric acid is dusted over 
the parts. This suffices to preserve an aseptic condition, while 
a complete absence of fluid causes a more speedy return to a 
normal condition. 

In cases of spontaneous rupture the opening may be so 
small that drainage is not perfect. When these cases are seen 
late in the course of the disease, our first efforts should be 
directed toward enlarging the opening and thoroughly cleans- 
ing the tympanic cavity by driving out the contained fluid 
with the air douche. If this does not suffice, the tympanum 
may be washed out with a saturated solution of boric acid by 
means of the middle-ear syringe (shown in Fig. 99). If exam- 
ination shows the lining mucous membrane to be considerably 
thickened, the instillation of a few drops of a two-per-cent solu- 
tion of nitrate of silver or a four-per-cent solution of sulphate of 
zinc suffices to correct the condition. In many cases a single 
application is followed by a complete cure. The medicinal solu- 
tions are instilled either with the middle-ear syringe or a simple 



TREATMENT— IRRIGATION. 



339 




Fig. 99.- 



-Blake's middle-ear 
syringe. 



middle-ear pipette of glass. Care should be taken when nitrate 
of silver is used to begin with a very weak solution, since the 
patient may possess a peculiar idio- 
syncrasy toward this drug, and the 
reaction following its application 
may be severe. If, after the first 
trial, we find the parts tolerant, the 
strength may be gradually increased 
until the desired results are obtained. 
When the pharynx is filled with hy- 
pertrophied lymphatic tissue, we find 
that the case is particularly liable to 
a relapse when the discharge has 
almost ceased. There is no reason 
why the presence of an otitis media 
of this character should influence us 
to delay the removal of the hyper- 
trophied lymphatic tissue after the 
acute aural symptoms have subsided. 
Its removal will be necessary to pre- 
vent subsequent similar seizures, and 
will certainly favor a rapid termination of the present attack. 

After the opening of the membrana tympani is closed, the 
patient should be kept under observation until the parts pre- 
sent a perfectly normal appearance. A certain amount of re- 
laxation of the drum membrane and of the intratympanic lig- 
aments follows an inflammation of this character, and may result 
in the formation of adhesions in the tympanum unless certain 
measures are instituted to prevent it. Inflation of the middle 
ear should be practiced at first daily, and subsequently at longer 
intervals, until all traces of congestion disappear and the mem- 
brane retains its normal position. 

In these cases, and also in instances where the membrana 
tympani remains intact, a certain amount of fluid may be left 
in the middle ear. The application of stimulating vapors to 
the lining membrane of the cavity will hasten absorption of this 
residual fluid. For this purpose nothing is better than the 
vapor from an alcoholic solution of menthol, sixty grains to 
the ounce. Oil of eucalyptus, or pine-needle oil of the strength 
of a drachm to the ounce, may also be employed, the vapor 
being conveyed to the middle ear through the Eustachian cathe- 
ter. The introduction of simple or medicated steam into the 



340 



ACUTE CATARRHAL OTITIS MEDIA. 



tympanum has fallen somewhat into disuse. It possesses no 
advantages over dry vapors, and its use is attended with a cer- 
tain amount of discomfort to the patient and is tedious for the 
operator. 

Subjective noises may persist for a considerable time after 
hearing has returned to a practically normal condition. The 
question of a secondary inflammation of the labyrinth presents 
itself at this period. From observation of a large number of 
patients we find that the labyrinth is seldom seriously involved 
in this disease. The subjective noises ultimately disappear 
when the mucous membrane of the tympanum returns to an 
absolutely normal condition. The failure of this symptom to 
disappear need give rise to no uneasiness. When the noises 
are particularly distressing, relief is obtained by the administra- 
tion of dilute hydrobromic acid in doses of thirty to forty-five 
minims two or three times daily. The susceptibility of the re- 
ceptive centres is blunted, and after the noises have once dis- 
appeared they seldom recur. It is wise to avail ourselves of 
the use of the drug, since the continued stimulation of this 
part of the receptive apparatus rather militates against an early 
disappearance of the symptom. 



CHAPTER XX. 

ACUTE PURULENT OTITIS MEDIA. 

The presence of pus in any locality depends upon a ne- 
crotic process involving the deeper tissues of the region. In 
the middle ear the upper portion of the tympanic cavity pre- 
sents an exceedingly favorable site for the development of a 
purulent inflammation, since in this region considerable con- 
nective tissue is present, forming the framework of the mucous 
reduplications of the tympanic vault, as well as of the ligamen- 
tous bands fixing the ossicles to the walls of the tympanum and 
uniting them to each other. 

A purulent otitis media primary in character is indicative 
of an infection in this region, as distinguished from a similar 
process involving the lower portion of the tympanic cavity. 

^Etiology. — In order that tissue necrosis may take place, 
the organism producing it must possess a certain amount of 
virulence. One of the most common causes, therefore, of puru- 
lent otitis media is some acute infectious disease. The affection 
most frequently followed by the disease under consideration 
is scarlatina, although it may appear during the course of pneu- 
monia, epidemic influenza, variola, typhus, or cerebro-spinal 
meningitis. It often follows the introduction of fluid into the 
middle ear through the Eustachian tube. The extension of an 
external otitis, either diffuse or circumscribed, may set up a 
purulent otitis media, access to the middle ear being gained 
through the Rivinian segment. The rupture of the drum mem- 
brane, either from any foreign body introduced into the meatus 
or by violent inflation of the tympanum, may be followed by a 
similar result. 

Occasionally vegetable molds developing in the canal in- 
volve the middle ear by continuity. A purulent inflammation 
in any other part of the body may infect the tympanic cavity 
secondarily, although this is an uncommon occurrence. As 
stated in the previous chapter, the disease may follow an acute 

(341) 



342 



ACUTE PURULENT OTITIS MEDIA. 



catarrhal otitis media by infection of the exudation either 
through the Eustachian tube or after it has gained an exit 
through the drum membrane and appeared in the external 
meatus. 

Pathology. — The first stages of the process consist in a 
hyperemia of the affected parts. The folds in the vault of 
the tympanum become engorged with blood, increase in vol- 
ume, and often fill the space completely, shutting off all com- 
munication with the atrium. This period of congestion is 
followed by a transudation of the fluid elements of the blood 
and a migration of white blood cells. Following this, local 
necrosis takes place, the tissue breaking down with the forma- 
tion of pus. A bacteriological investigation of the discharge 
in these cases will most frequently reveal a streptococcus infec- 
tion. Occasionally a pneumococcus will be found. In order 
that the connective-tissue structures of the vault may be in- 
vaded, it is necessary that the germ causing the infection should 
be one of considerable virulence, the less active varieties of 
infectious germs not being sufficiently virulent to attack con- 
nective-tissue structures. As the result of the local oedema 
the blood supply of the ossicular chain is considerably interfered 
with, and bony necrosis may occur quite early. This usually 
takes place first in the incus, on account of the limited blood 
supply in proportion to its size, and the fact that its nutrient 
vessels pursue such a course as to be subjected to pressure 
quite early in the attack. The surrounding walls of the tym- 
panum may also become involved, although this rarely occurs 
early in the disease. Occasionally the process may start as an 
acute osteitis either of some portion of the ossicular chain or 
of the bony walls of the tympanum, the soft parts being in- 
volved secondarily. This condition is occasionally met with 
in patients suffering from tuberculosis. 

After the inflammation is fully developed and the parts have 
become engorged with blood, transudation of the fluid ele- 
ments of the blood takes place, together with migration of the 
white blood-corpuscles which pass out of the vessels into the 
surrounding tissue; the fluid transuded naturally gravitates to 
the lowest portion of the cavity. The exact position occupied 
by the fluid will depend upon the particular formation of the 
tympanum in any individual case; occasionally the mucous folds 
are so developed that the transudation is confined and does not 
enter the general tympanic cavity. It will be remembered 



PATHOLOGY. 343 

that the long process of the incus passes downward from the 
body of the ossicle into the atrium; this fact plays an important 
part in the cases under consideration, since, when the tissues 
within the tympanic vault are much swollen, the long process 
of the incus forms a natural drain along which the fluids may 
pass into the lower portion of the tympanic cavity from the 
space above. We find that where the inflammatory products 
from the vault collect in the atrium and subsequently perforate 
the membrana tympani this perforation lies in the upper and 
posterior quadrant close to the tympanic ring and just below 
the incudo-stapedial articulation. The fact that perforations 
located in this region are persistent and that the inflammaory 
processes developed here are specially painful is a fact that has 
long been noted; its particular significance, however, has been 
explained but lately. Sometimes, owing to the topography 
of the organ, the upper part of the cavity is completely divided 
from the lower portion. The inflammatory products in these 
cases can not pass along the descending arm of the incus into 
the atrium, and therefore crowd the upper portion of the mem- 
brana tympani outward. This bulging of the membrana flac- 
cida is particularly characteristic, and is sometimes present to 
such a degree that the distended portion sinks down over the 
membrana vibrans, partially or completely concealing it from 
view. I have seen one instance in which the bulging was so 
extensive that the membrana flaccida protruded from the mea- 
tus and might easily have been mistaken for a polyp. Upon 
incision a large amount of fluid was evacuated, retraction took 
place, and examination revealed the opening in the superior 
quadrant just above the posterior fold. It is probable that those 
cases of otitis media in which the atrium seems to be the pri- 
mary seat of purulent inflammation are really instances in 
which the inflammatory products have passed from the vault 
into the atrium along the long process of the incus, as it is 
hardly possible for a purulent inflammation to originate in a 
cavity whose mucous lining is closely applied to the bony walls. 
Where evacuation does not occur, either spontaneously or at 
the hand of the surgeon, the fluid may dissect the soft tissues 
of the canal for a certain distance along" the superior and pos- 
terior wall, since in this region the periosteum of the canal is 
directly continuous with the membrana flaccida and is but 
loosely attached to the bony margin of the meatus. This 
gives rise to a sinking of the postero-superior wall of the meatus 



344 



ACUTE PURULENT OTITIS MEDIA. 



and a narrowing of the deeper portion of the canal. The pus 
may burrow along the entire length of the wall and make its 
appearance in the post-auricular region as a soft, fluctuating 
swelling. This is particularly liable to occur in children, where 
the tissues are less firmly attached to the parts beneath, and 
the membrana tympani is so superficially placed. Cases of this 
class are particularly prone to mastoid complication. 

Examination of a large number of cases teaches us that the 
mastoid is usually involved before the soft parts covering the 
postero-superior wall of the canal become detached from the 
underlying bone. Hence, evidence of a collection of fluid in 
this region constitutes an almost pathognomonic sign of mas- 
toid inflammation. In children, where the purulent collection 
has dissected off the posterior wall of the canal and formed a 
post-aural abscess, the periosteum on the outer surface of the 
temporal bone may become detached unless the fluid is freely 
evacuated, and infection of the intracranial structures may take 
place either through the mastoid squamous fissure which re- 
mains open for a considerable period after birth, or a local- 
ized caries or necrosis of the squamous portion may take place 
on account of interference of the blood supply, and direct in- 
fection follow. Several cases of this character have been re- 
ported, and it has fallen to my lot to witness two * — one in a 
child and one in an adult. The involvement of the cranial con- 
tents in this manner is the exception, the infection usually tak- 
ing place either through the tympanic roof or through one of 
the large venous sinuses in the immediate neighborhood of the 
middle ear. Either condition may occur by a transmission of 
the infecting material through the communicating venous chan- 
nels, or local caries may take place and a large amount of pus 
be brought in contact with the surface of the meninges or 
enter directly into the blood current through one of the large 
sinuses. 

Symptomatology. — The characteristic symptoms of an 
acute purulent otitis is sudden and excruciating pain deep 
within the ear. Attending this we have a decided elevation 
of temperature, the thermometer registering from ioi° to 103 , 
severe headache, constipation, and marked constitutional de- 
pression. The hearing becomes rapidly impaired, there is 
often distressing tinnitus, and in some cases vertigo. When 

* Archives of Otology, vol. xxi, p. 253. 



SYMPTOMATOLOGY. 



345 



the disease occurs in children the symptoms are even more 
marked, the attack being frequently ushered in with general 
convulsions. The pain changes quickly from one localized 
within the ear to a rather diffuse headache upon the affected 
side. In severe cases even in adults delirium is occasionally 
present. High temperature in marked contrast to the very 
moderate increase observed in an acute catarrhal inflammation 
indicates the more profound constitutional infection. The pain 
continues unabated unless relieved artificially until the inflam- 
matory products are evacuated. This may not occur for sev- 
eral days if the condition is not interfered with. The occurrence 
of discharge offers some relief to the pain, although it does 
not entirely remove it, since the tissues are so oedematous that 
the opening is seldom large enough to permit free drainage. 
The fluid that fills the auditory canal is usually at first sero- 
purulent, but quickly changes to a distinctly purulent charac- 
ter. Involvement of the mastoid cells may occur before the 
appearance of discharge or at a subsequent period. In either 
event it is characterized by increased pain, and an augmenta- 
tion in the severity of all of the general symptoms. The loca- 
tion of pain changes somewhat and is referred to the region 
immediately behind the auricle rather than to the ear itself. 
Involvement of the structures within the cranial cavity is usu- 
ally characterized by an increase in the temperature, violent 
delirium, convulsive movements followed by paralysis or pare- 
sis, either upon the corresponding or the opposite side, accord- 
ing to the particular area involved. When invasion of one of 
the large sinuses of the dura mater takes place either from the 
middle ear itself or from the subsequent mastoid involvement, 
symptoms of pysemic infection appear. These are a sudden 
high temperature, frequently reaching 105 or 106 , with an 
equally sudden return to normal or even to subnormal, pro- 
fuse sweating, and rigors. These changes in temperature are 
repeated at intervals varying from a few hours to one or 
two days. 

Evidences of extension to the labyrinth are the sudden ap- 
pearance of dizziness, nausea, and either absolute deafness for 
all notes or complete loss of perception for certain portions 
of the musical register, usually the high notes of the scale. 
Extension in this direction is rather unusual, a fact which 
would suggest that the vascular communication between the 
middle ear and the labyrinth through the intervening bony 
24 



346 ACUTE PURULENT OTITIS MEDIA. 

wall is not as extensive as the investigations of Politzer * would 
cause us to believe. 

Diagnosis. — A. Physical Examination. — Recognition of this 
condition in its very early stages is of the utmost importance, 
since the disease is always a severe one, being dangerous not 
only to the function of the organ, but often to life itself. Par- 
ticular attention should be given to an inspection of those parts 
lying above the short process of the malleus whenever severe 
pain in the ear is complained of. It is the rule that in the 
very early stage that portion of the membrana tympani alone, 
lying above the short process of the malleus, is the only part 
which presents the slightest departure from the normal appear- 
ance. Here close inspection will reveal the fact that the mem- 
brane is distinctly congested, presenting a deep dull-red color 
characteristic of a high degree of venous engorgement of the 
underlying structures. This hyperaemia does not extend below, 
and frequently not as far as the posterior fold, and, if a hasty 
examination be made, may entirely escape observation. It is 
in this very early stage that prompt measures may serve to 
abort the attack; hence the stress which is laid upon the phys- 
ical characteristics. 

When viewed somewhat later, well-marked engorgement 
of these structures is seen to be present, the membrana flac- 
cida being pushed outward and somewhat down- 
ward (Fig. ioo). The entire region is of a deep- 
red color, the parts being cedematous, the exter- 
nal surface moist, and the normal lustre entirely 
wanting. The tumefaction may be so great as 
to actually sink downward into the canal to the 
pumienT otitis l eve l of the short process, or may overhang it. 
media ; bulging When well advanced, the hyperaemia becomes 

of membrana . « . . . 

flaccida. general, and involves the entire tympanic mem- 

brane. Sometimes the short process may be 
completely hidden by the oedema of the surrounding parts, 
although this landmark can usually be found if sought for care- 
fully. The outline of the manubrium is almost always lost. 

In cases complicating scarlatina, or any disease where the 
infection has been sudden and violent, an appearance which 
may deceive is one in which the membrana tympani presents 
a dead-white color. This is due to a necrosis of the superfi- 

* Arch, ftir Ohrenheilk., vol. xi, p. 237. 





DIAGNOSIS. 347 

cial epithelium covering it, the loss of lustre being character- 
istic of the condition. This superficial layer is easily removed 
by the cotton-tipped probe, and reveals the red membrane be- 
neath. Where fluid has drained into the lower portion of the 
tympanic cavity the entire membrana tympani may bulge into 
the canal instead of presenting a localized bulging area at the 
upper part. The appearance then does not differ from that 
shown in Fig. 98. The secretion may be so confined by the 
mucous folds within the tympanum as to present, upon exam- 
ination, several tumefied masses lying in the fundus of the 
canal close to the superior wall. These may be two or three 
in number, according as the fluid is confined in the anterior and 
posterior pockets of the membrane, or has entered these and 
the median space known as the pocket of 
Troeltsch as well (Fig. 101). Inspection of 
such a case, where a clear history can not be 
obtained as to the length of time the disease 
has lasted, is misleading, the bulging areas 
being frequently mistaken for masses of granu- 
lation tissue. Where perforation has taken fig. ior.— Acute 
place spontaneously, we most frequently find purulent otitis 
the opening in the posterior portion of the confined in the 
membrane, just above the centre and near its pockets of the 

' J membrane. 

peripheral attachment. It may also appear 

above the posterior fold and be entirely within the membrana 

flaccida. When this occurs it usually forms the apex of an 

irregular conical projection from Shrapnell's membrane, the 

margins of the perforation being swollen and irregular in 

outline. 

Forcing air into the middle ear through the Eustachian 
tube before perforation has taken place may not reveal the 
presence of fluid, since the collection may be confined entirely 
to the vault. After perforation has taken place, even vigorous 
efforts at inflation may not force air through the opening in 
the drum membrane, and give rise to the characteristic per- 
foration whistle. It may even fail to force any secretion from 
the tympanic cavity on account of the extreme swelling of the 
lining membrane. 

B. Functional Examination. — The functional examination in 
these cases reveals a condition identical with that described in 
the preceding chapter on acute catarrhal otitis media. 

When the labyrinth is encroached upon by extension 



348 ACUTE PURULENT OTITIS MEDIA. 

through the oval or round window, we find, in addition, the 
diminution in bone conduction and loss of perception of upper 
notes of the scale. 

Prognosis. — An otitis media of this variety can terminate 
in spontaneous recovery without loss of tissue only when 
the inflammatory process does not progress beyond the stage 
of congestion. When once pus is formed it must be evacu- 
ated, and hence resolution is impossible after this period. 
With the evacuation of the fluid the perforation may heal and 
the parts be restored to their normal condition. Such a for- 
tunate termination is seldom to be looked for, however, un- 
der the most favorable conditions, and cases which are un- 
treated usually present, after the disease has run its course, a 
destruction of the membrana tympani over a greater or less 
area. 

The internal wall of the middle ear may be covered by a 
cicatrix extending from the margins of the opening in the 
tympanic membrane to the osseous wall of the middle ear, 
practically converting it into a closed cavity. In other instances 
where the membrana tympani has been almost completely de- 
stroyed we find the internal wall presenting a pale, glazed 
appearance; the parts are perfectly dry, and the mucous mem- 
brane has become changed to one which does not secrete 
moisture. Again, the internal Avail of the tympanum may be 
somewhat thickened and moistened by its normal mucous 
secretion without any discharge appearing in the canal. The 
ossicular chain is usually bound down to the internal tympanic 
wall at various points by cicatricial bands. The amount of 
interference with the function varies in different cases and de- 
pends upon the location of adhesions. 

In the majority of instances, in cases which have been un- 
treated during an acute attack, a chronic purulent otitis devel- 
ops, and careful investigation will show areas of bony necrosis 
either in the walls of the tympanum or confined to the ossicular 
chain. The location of the perforation and its diagnostic sig- 
nificance in cases where the discharge persists will be more 
fully dwelt upon in the consideration of chronic purulent otitis 
media. 

Death may result from the disease, from direct involvement 
of the cranial contents, either directly or after the development 
of mastoid inflammation. This last complication is of common 
occurrence where the disease does not come under observa- 



TREATMENT— INCISION. 



349 



tion in the acute stage. The prognosis as to the integrity of 
function is rather better than might be expected when we con- 
sider the extensive loss of substance which the malady entails. 
Serious labyrinthine involvement is decidedly the exception, 
and when the labyrinth is involved the invasion is usually pri- 
mary, dependent upon the same cause that has produced mid- 
dle-ear inflammation, rather than secondary to the tympanic 
disease. 

Treatment. — Vigorous measures must be instituted in the 
earliest stages if we hope to abort the affection. When in 
the course of an acute infectious disease severe pain is com- 
plained of in the ear, and inspection reveals the characteristic 
congestion already mentioned, immediate local depletion should 
be instituted. As much blood as the general condition of the 
patient will permit should be abstracted from the region in 
front of the tragus. The administration of an opiate to relieve 
pain is not advisable in these cases, since whatever measures 
are to be instituted for the relief of the local condition must 
be employed in the course of a few hours, and it is unwise 
to mask any advance of the disease by blunting the suscepti- 
bility of the patient to the intensity of the pain. If local deple- 
tion does not produce immediate relief, the parts should be 
thoroughly incised. This operation is intensely painful, but 
quickly performed, and the wisdom of administering a general 
anaesthetic must depend upon the condition of the patient. 
During the last few years I have operated on most of these cases 
under nitrous oxide anaesthesia, and have found it satisfactory 
in every instance. The incision should lie above the short 
process of the malleus and posterior to it. The knife is en- 
tered just behind the processus brevis and carried upward and 
inward parallel to the neck of the malleus until it has pierced 
the cellular tissue within the tympanic vault and impinges upon 
the bony wall. The knife is then swept backward to the periph- 
ery of the membrane, the deep tissues being divided throughout 
the entire extent of the incision. If the long process of the 
incus is encountered, as may happen if it lies high up in the 
cavity, or if the incision is carried a little too low, care must be 
taken not to displace it, the knife being allowed to glide over 
it, and afterward being pushed inward to the original depth to 
complete the incision. It is well, also, on reaching the periph- 
ery, to extend the section directly outward along the supero- 
posterior wall for a distance of a quarter of an inch, dividing 



350 ACUTE PURULENT OTITIS MEDIA. 

all the soft parts down to the bone. Very free bleeding follows 
this operation, and the haemorrhage should be encouraged by 
irrigation of the canal with warm boiled water. It is to be dis- 
tinctly understood that we do not expect to liberate pus by this 
procedure., but to prevent its formation. Consequently the 
greatest care must be taken that the field of operation is in an 
aseptic condition, and that all instruments and the fluid used 
subsequently in irrigating the region are thoroughly aseptic. 
This measure, when performed sufficiently early, may com- 
pletely abort the attack: the divided tissues unite firmly at the 
end of a few days, and all symptoms referable to the ear may 
disappear completely. When seen at a later period, and when 
the parts are distinctly bulging, it is wise to van* the procedure 
to the extent of beginning the incision over the area of the 
greatest bulging, remembering that our object is to incise the 
vascular tissues located in the superior portion of the cavity. 
and to liberate any contained fluid as well. Here, instead of 
carrying the incision outward upon the canal wall, the knife 
may be plunged directly into the most prominent portion of 
the tumor, carried deeply into the tympanic vault, and the 
parts divided directly upward as far as the superior margin 
of the meatus (Figs. 87 and 97); the peripheral attachment of 
the membrane posteriorly should then be followed downward 
for a short distance, thus forming a triangular flap, to favor 
free drainage. When spontaneous perforation has taken place 
we usually find it necessary to enlarge the opening. This meas- 
ure should be carried out according to the rule which governs 
the primary incision. 

Upon the appearance of discharge after spontaneous rup- 
ture, or after surgical interference, the canal must be kept as 
free as possible by frequent irrigation with a warm antiseptic 
solution. This not only tends to relieve pain by depleting the 
tissues, but is of the greatest importance in preventing a local- 
ized infection of the canal. The development of a furuncle 
during the course of the disease is to be especially avoided, 
as it may mask an involvement of the mastoid process, or 
may be mistaken for this condition. A localized tumefaction 
of the canal indicative of mastoid involvement is situated at 
the fundus, upon the postero-superior wall of the meatus, and 
close to the drum membrane (Fig. 78). In this region the de- 
velopment of a primary infectious process in the canal wall is 
exceedingly rare, circumscribed otitis externa usually occur- 



TREATMENT— MASTOID INVOLVEMENT. 35 1 

ring in the fibrocartilaginous portion. Tenderness upon deep 
pressure over the mastoid, care being taken not to communi- 
cate any motion to the movable part of the canal during the 
examination, will also aid us in deciding that the mastoid is 
involved, while tenderness on pressure about the ear, which 
imparts a certain amount of motion to the fibro-cartilaginous 
portion of the meatus, or on traction upon the auricle, will 
point to a circumscribed external otitis of a simple character. 

When the symptoms point to mastoid involvement, great 
caution is necessary in order that measures may be undertaken 
at a sufficiently early period to prevent this complication. 
With the accession of any tenderness over the mastoid region, 
either directly over the antrum or at the apex, the Leiter coil 
or aural ice bag may be applied and kept in position continu- 
ously for a period of not over thirty-six hours. In addition to 
this, attention should be given to the primae vise. The diet 
should be light, and any tendency to constipation should be 
overcome by the free use of saline cathartics. Any tumefac- 
tion of the tissues at the upper and posterior part of the bony 
meatus close to the drum membrane should be immediately 
incised, since the relief of tension here, in conjunction with 
cold externally and frequent irrigation of the canal, will usually 
abort the attack. Here, again, it is not advisable to administer 
drugs for the purpose of relieving pain, or certainly not for 
any long period. If the pain in the mastoid region remains 
moderate for twenty-four hours, and manipulation elicits an 
increase in the amount of tenderness, it may be wise to insure a 
fair amount of sleep for one night by the administration of 
morphine. This plan should not be repeated, for if on the fol- 
lowing day no marked amelioration of the symptoms is present, 
operative measures directed to the mastoid process should be 
at once instituted. I was formerly much more in favor of the 
use of the ice-coil as an abortive measure in the treatment of 
mastoiditis than I am at present. A more extensive experience 
has taught me that the cases of mastoid congestion which will 
be prevented from going on to suppuration and to extensive 
destruction of the bony tissues by means of the ice-coil are 
exceedingly rare. At present I am in favor of using abortive 
measures of any kind only in the very earliest stages of the dis- 
ease. If a case is seen within twenty-four or forty-eight hours 
from the beginning of the acute otitis, and if at this time some 
mastoid tenderness is present, the surgeon is then justified, 



352 ACUTE PURULENT OTITIS MEDIA. 

after establishing free drainage through the meatus, in applying 
the ice-coil to the mastoid for a period of thirty-six, and possi- 
bly for a period of forty-eight hours, but certainly for no longer 
time. At the end of this time the ice-coil should be removed 
and should not be reapplied. Any beneficial effects which will- 
result from the local application of cold will have been obtained 
at the end of thirty-six to forty-eight hours. If tenderness per- 
sists after the use of cold for this length of time, no further 
abortive measures should be attempted, but the surgeon should 
enter the mastoid at once. In doubtful cases the otologist is 
perfectly justified in exposing the mastoid antrum for explora- 
tory purposes. Under proper aseptic precautions, no harm 
can result from this operation, and early interference may save 
the patient a prolonged convalescence following a more severe 
operative procedure. I can hardly speak favorably of local 
bloodletting over the mastoid region. Occasionally it may be 
followed by relief; but my experience has been that, where 
blood has been abstracted from this region, the symptoms 
have been delayed only, but the complication has not been pre- 
vented. Another objection to local bloodletting lies in the fact 
that the tenderness of the parts to which the measure gives 
rise may mask that due to the inflammation of the osseous 
structures. This is not a serious objection, to be sure, and a 
little care on the part of the surgeon will enable him to dis- 
tinguish between superficial and deep tenderness. At the same 
time it is important for us to recognize the fact of mastoid in- 
volvement as soon as it takes place, and not delay prompt inter- 
ference. Any measures which temporarily relieve the symp- 
toms, or cause the disease to progress more slowly, are of a 
decided disadvantage, and often a menace to life. The par- 
ticular operative measures to be adopted when the mastoid is 
involved will be fully described in the section devoted to sur- 
gery. It should be stated here, however, that the author is 
decidedly averse to the employment of a simple incision over 
the mastoid in these cases. The value of the so-called " Wilde's 
incision " depends upon the depletion and a certain amount 
of relief to tension secured by division of the periosteum. The 
operation is exceedingly painful, and a general anaesthetic is 
usually necessary. In all cases where the Wilde incision is 
positively demanded it will probably be necessary to enter the 
mastoid at a later period; and to give the patient an anaesthetic 
upon one day for the purpose of making a superficial incision, 



TREATMENT— DRAINAGE. 



353 



and to repeat it a day later for the purpose of completing the 
operation and entering the mastoid process itself, is absolutely 
unjustifiable. When, therefore, external incision seems indi- 
cated, but the surgeon does not feel justified in entering the 
bone, it is much better to wait for twenty-four or forty-eight 
hours, at which time no doubt will exist as to the proper course 
to pursue. Incision within the canal has already been spoken 
of, and is in reality an internal Wilde's incision. The pneu- 
matic cells of the mastoid are located much nearer the superior 
wall of the meatus than to the external surface of the mastoid 
cortex. This incision in the canal frequently relieves tension 
sufficiently to prevent an extension of the inflammation. 
Whenever internal incision will not relieve the condition within 
the mastoid, external incision certainly will not, and in adults 
it should be a cardinal rule never to depend upon the operative 
measure of dividing the soft parts alone. In children under 
three years of age, where the mastoid cortex is thin and the 
cells may be opened with a stout scalpel, the procedure may 
occasionally be justifiable; but even here experience has taught 
me that a complete operation under general anaesthesia is better 
than to incise the superficial structures simply and secure imper- 
fect drainage. The opening must be small, and no knowledge 
of the extent of the tissue involved can be gained, while the 
exit to the discharge can not be free. Therefore, whenever any 
operative procedure is instituted upon the mastoid it should 
be thorough, and should be performed under general anaes- 
thesia. 

We occasionally meet with cases which, after incision of the 
membrana tympani and the establishment of drainage, progress 
favorably for a certain period, after which — probably because 
of a fresh access of inflammation — the discharge increases in 
amount, the pain returns, and the symptoms are repeated, 
although not to the same degree. Here it may be necessary 
to re-incise the drum membrane and thoroughly evacuate the 
contents of the tympanic cavity. Each recurrence incurs the 
danger of mastoid inflammation, and to delay the establish- 
ment of free drainage through the external meatus, in the hope 
that the inflammatory process may disappear spontaneously, 
is certainly unwise. If the parts are kept thoroughly cleansed 
and attention is paid to the proper exit of the discharge, very 
little local treatment is necessary aside from this. Occasion- 
ally, owing to the impoverished general condition of the patient. 



354 



ACUTE PURULENT OTITIS MEDIA. 



or to some obstructive lesion in the upper air passage, espe- 
cially to enlargement of the pharyngeal tonsil in children, the 
discharge becomes small in amount and assumes a watery char- 
acter, but does not cease completely. Here attention to the 
general health is of prime importance, since if the discharge 
is allowed to continue too long the ossicles are apt to become 
involved, and a chronic purulent otitis may be established. If 
the pharyngeal vault is the seat of adenoid vegetations, these 
should be removed. 

While it may occasionally be justifiable to incise the mem- 
brana tympani a second time, in the hope of preventing the 
extension of an inflammatory process to the mastoid, I am in- 
clined to believe that where a myringotomy has been done once, 
and been done thoroughly, and where the incision has been 
carried out on to the upper wall of the canal, in the manner 
already described, the surgeon will be wasting time in attempt- 
ing to relieve the patient by a second incision of the drum mem- 
brane. Of course, it is possible, as stated above, that reinfec- 
tion may occur at a comparatively late date and after the open- 
ing in the membrana tympani has almost entirely healed; these 
cases, however, are extremely rare. Where the drum mem- 
brane has been once thoroughly incised and at a later date 
symptoms of incomplete drainage make their appearance, it 
is better to open the mastoid at once and to secure free drainage 
posteriorly, than to temporize by resorting to a second my- 
ringotomy. Such a procedure will probably fail to relieve the 
patient, and the necessity of operative treatment on the mastoid 
will be simply postponed and not prevented. We know from 
experience that the longer such operative treatment is delayed, 
the more extensive is the destruction of the bony tissues. It 
is wise, therefore, for the surgeon to open the mastoid upon the 
first evidence that drainage through the meatus is incomplete. 

In case the discharge does not cease as promptly as might 
be expected, owing to inattention on the part of the patient 
regarding thorough cleansing of the canal, granulation tissue 
may develop along the margins of the incision or spontaneous 
perforation in the membrana tympani, or the mucous mem- 
brane within the tympanic cavity may become greatly hyper- 
trophied and protrude through the perforation in the form of 
a pedunculated mass, constituting an aural polyp, so called. 
This obstructs the free outflow of the secretion, and must be 
either removed or destroyed in situ. Removal may be easily 



TREATMENT— SOLUTIONS. 355 

effected by means of a delicate snare armed with fine wire. For 
destroying these exuberant granulations either chromic acid 
or the fused bead of nitrate of silver may be used. Care should 
be taken to thoroughly dry the granulations before the escha- 
rotic is applied and to make the application to the hypertro- 
phied tissue only, and not allow it to spread to the surrounding 
parts. This is effected by lightly touching the parts which 
have been cauterized with a pledget of dry cotton immediately 
after cauterization, to remove any excess of the agent employed. 
If delicately executed, the procedure is not painful, but it is 
always wise to anaesthetize the part with a ten-per-cent solu- 
tion of cocaine, previous to cauterization. Chromic acid, I 
think, is the safer agent to employ, as nitrate of silver is some- 
times followed by a rather sharp reaction. 

Again, the hypertrophied covering of the internal tympanic 
wall, instead of assuming a distinctly polypoid appearance, may 
present as a diffuse thickened membrane. This occurs espe- 
cially when the perforation is of large size, exposing the tym- 
panum over a considerable area. Here we make use of the 
metallic astringent salts in aqueous solution, nitrate of silver 
being the favorite, although sulphate of copper, sulphate of 
zinc, chloride of zinc, or the persulphate of iron may be em- 
ployed probably with equally good results. The strength of the 
solution used must vary with the special condition of the parts. 
It is always well to test the susceptibility of the patient by 
beginning with weak solutions and to increase the strength 
according to indications. The silver solutions may be used in 
strengths of from two to fifty per cent; the zinc salts in strengths 
of from two to four per cent. If sulphate of copper is employed 
the degree of concentration should not exceed ten or fifteen 
grains to the ounce. 

The persulphate of iron seems to be of particular value in 
causing a rapid disappearance of granulations developed about 
the margins of a perforation. The solution may be used full 
strength or diluted with water, according to the size and char- 
acter of the granulations. The patient should be seen the day 
following such applications, as occasionally the reaction will 
cause closure of the opening in the drum membrane, and 
symptoms dependent upon pus retention may supervene. 

When only a small quantity of discharge remains we may 
find that the use of fluid in the canal increases rather than 
diminishes the amount of discharge. If the case is watched 



356 ACUTE PURULENT OTITIS MEDIA. 

closely, astringent or antiseptic powders may be employed, 
care being taken that the opening in the membrana tympani 
is not occluded, the powder being insufflated so as to form 
a thin covering over the membrana and the canal walls. If 
this plan is adopted the patient must be seen daily by the 
surgeon and the parts thoroughly cleansed by means of the 
cotton pledget, after which the powder is lightly dusted over 
the membrana tympani, the granulations, or the exposed wall 
of the middle ear, as the case may be. We may use boric 
acid, iodoform, iodol, or dermatol. When the walls of the 
canal appear sodden from long-continued irrigation, the addi- 
tion of a small amount of oxide of zinc to any of the above 
powders is desirable. This protects the denuded lining of the 
meatus and favors the formation of normal epithelium. After 
the opening in the drum membrane is closed, inflation should 
be employed at first daily, the interval being increased as the 
parts resume their normal appearance. It is important that 
this plan should be carried out; otherwise adhesions may de- 
velop in the tympanum and the function of the organ be 
decidedly impaired. 



CHAPTER XXI. 

CHRONIC CATARRHAL OTITIS MEDIA. 

Under chronic catarrh of the middle ear various affections 
of the tympanum have been described. The selection of this 
name is particularly unfortunate, since it conveys the impres- 
sion that the disease is really a complicating lesion of some 
condition in the nose or naso-pharynx. " Catarrhal deafness " 
is a term which appears not only in our standard works upon 
otology, but also forms a prominent feature of the advertise- 
ment of almost every charlatan. 

In the first place, catarrh as a disease does not exist, it 
being merely a term used to describe a symptom, meaning 
from its derivation simply a discharge. By common consent 
catarrhal inflammation is the term applied to a simple inflam- 
mation of any mucous membrane. It may occur in the ear 
or elsewhere, constituting a primary disease entirely inde- 
pendent of any lesion in the upper air passages. 

When the mucous membrane of the middle ear is the seat 
of such a chronic inflammatory process the changes which 
take place are of two varieties : In one form, which may be 
termed a hypertrophic inflammation, we have a swelling of 
the lining membrane of the tympanum, due usually at first 
to a chronic venous congestion ; this continuing for a long 
period results in hypertrophy of the elements of the tissue 
lining the cavity. Over the bony internal wall of the mid- 
dle ear the mucous membrane is thickened and hyperasmic 
and the glandular elements produce, therefore, an excessive 
amount of secretion. In the drum membrane the same pro- 
cess takes place ; the fibrous layer becomes thickened in 
places, and may over certain areas be the seat of calcareous 
deposits. The same changes take place in the ossicles, liga- 
ments, and in the walls of the Eustachian tube. Owing to 
the chronic hyperasmia, serum or sero-mucus may collect in 
the cavity and remain there permanently, or the fluid may dis- 
appear from time to time when the congestion is less marked. 

(357) 



358 CHRONIC CATARRHAL OTITIS MEDIA. 

In contradistinction to these changes, we find in another 
class of cases a process characterized by tissue hyperplasia 
rather than by hypertrophy ; the new tissue is firm and fibrous 
in character, secretion is diminished, the walls of the ves- 
sels supplying the parts are thickened, and a true sclerosis 
results. In this form of inflammation the favorite site of the 
inflammatory process is the region of the oval and round win- 
dows. The outer wall of the tympanum — that is, the mem- 
brana tympani — may present almost no variation from the nor- 
mal appearance. In the Eustachian tube the tissue changes 
cause an actual increase in the calibre of the canal as the mem- 
brane becomes firmer and more closely applied to the parts 
beneath. In the tympanic ligaments this sclerotic process in- 
creases their firmness, binding the ossicles rigidly together 
and fixing them firmly within the cavity, so that the degree 
of motion in every direction is much reduced. About the sta- 
pedial niche we find dense connective-tissue bands running 
from the head of the stapes and from the crura to the walls 
of the pelvis ovalis. The motion of this ossicle is therefore 
greatly limited. At the round window similar changes pre- 
vent, the compensatory movements of the membrana tympani 
secondaria and render the vibratory motion of the labyrin- 
thine fluid difficult or impossible. Whether the hyperplastic 
form of inflammation is often secondary to the hypertrophic 
form is a mooted question, but the weight of evidence seems 
to favor this view. 

Chronic Hypertrophic Otitis Media. 

^Etiology. — A chronic hypertrophic inflammation within 
the tympanum may follow an acute catarrhal otitis, an acute 
congestion of the Eustachian tube which has failed to resolve 
completely, or a similar process in which the middle ear and 
tube are both involved. It may also occur as an idiopathic 
affection, the organ never having been the seat of an acute in- 
flammation. In any case where the disease is chronic from 
the beginning it depends upon some fault in the manner of life 
of the patient through which he becofmes particularly suscep- 
tible to vascular changes in those portions of the body lined 
with mucous membrane. Frequent exposure to cold result- 
ing in repeated attacks of acute rhinitis or acute naso-pharyn- 
gitis,. from which the vessels within the tympanum are fre- 
quently engorged with blood, is a most common cause. The 



ETIOLOGY. 



359 



condition may begin in early life from the presence of a mod- 
erate amount of adenoid tissue in the pharyngeal vault, not 
enough to give rise to symptoms of nasal obstruction, but suf- 
ficient to cause a venous engorgement of its parts with each 
exposure to cold. This condition interferes with the intra- 
tympanic circulation, and, although the pharyngeal tissue may 
become entirely normal in later life, the changes set up within 
the middle ear may persist and even increase although the 
cause of the affection has disappeared. The disease is more 
commonly met with in individuals whose occupation renders 
exposure to inclement weather a matter of necessity ; it is 
hence more common in males than in females. No period of 
life is exempt from the disease, but it occurs more frequently 
between the ages of fifteen and thirty-five than before or after 
this period. Marked impairment of the general health, either 
from a severe illness, from prolonged mental anxiety, or from 
privation, constitutes a factor in the causation of many cases. 
The abuse of alcohol also exerts a certain effect in the pro- 
duction of the disease, both from its local action upon the di- 
gestive organs and its influence upon the circulatory system. 
We are often told that the aural lesion is due to the extension 
of inflammation from the pharyngeal vault because of the con- 
tinuity of anatomical structure. While this may be so, it is 
certainly a question of little importance, since the same causes 
acting to produce the pharyngeal inflammation may exert 
their effect primarily upon the lining membrane of the tym- 
panum. The excessive use of tobacco is not responsible for 
the disease under consideration, except as it may affect the 
general health ; the inhalation of smoke produces quite as 
deleterious an effect upon the respiratory organs and middle 
ear from local action as does the actual use of the weed. 

The opinion so prevalent, that impaired hearing due to 
catarrhal inflammation of the tympanum is to a certain extent 
hereditary, is not entirely borne out by experience. A care- 
ful examination of statistics shows that in the disease under 
consideration heredity plays a very unimportant part in the 
causation. It is true that certain families seem to show a 
particular predisposition to inflammations of the lymphatic 
type, engorgement of the lymph nodules occurring with any 
slight local inflammation. This is seen if we observe the fre- 
quency with which adenoid vegetations are observed in dif- 
ferent members of the same family through several genera- 



360 



CHRONIC CATARRHAL OTITIS MEDIA. 



tions. Since these growths exert an influence upon tympanic 
conditions, it is not strange that the belief should be held that 
the aural affection is transmitted from one generation to an- 
other. In many cases, however, we find the pharyngeal lym- 
phatics enlarged through several generations without any 
aural affection. It is probable, therefore, that the influence 
of heredity is limited to the lymphatic deposits, which render 
the ears more easily affected by slight changes. It is seldom 
that any hereditary history of the aural disease is met with 
without the accompanying lymphatic taint. 

Pathology. — The pathological changes have been described 
somewhat at length in the introductory remarks. To recapit- 
ulate, they consist in a swelling of the lining membrane of the 
tympanum, due at first to a venous congestion, but afterward 
to an actual tissue hypertrophy. The newly formed tissue 
is vascular and richly supplied with cellular elements, the 
fibrous elements being but little developed. An actual in- 
crease in volume is the result of this process, and is charac- 
teristic of this form of inflammation. The presence within 
the tympanum of a fluid exudation, due either to an abnor- 
mal activity of the secretory glands or to the transudation of 
the fluid elements of the blood from the engorged vessels, 
constitute another prominent feature. No particular por- 
tion of the middle ear is involved by preference, even the 
membrana tympani sharing in the changes wrought by the 
morbid process. In the membrana tympani there is thicken- 
ing of the mucosa and swelling of the fibrous layer, followed 
by true hypertrophy here, and in the advanced stages by a 
deposit of the lime salts. 

As involving the drum membrane, the structural changes 
produced are usually more marked in some parts of the mem- 
brana tympani than in others. This results in an irregularity 
of texture, some portions appearing dense and opaque, while 
others, by contrast, appear thinner than normal (see colored 
plates). In the Eustachian tube the tissue changes within 
the walls narrow its lumen, and prevent the entrance of air 
into the middle ear. This reduces the tension within the 
middle ear, and causes depression of the membrana tympani 
from atmospheric pressure. A gradual stretching of the drum 
membrane takes place from the continued pressure from with- 
out, until finally further displacement is prevented by contact 
with the internal tympanic wall. The pressure against this 
resisting barrier increases the local inflammatory process. 



PATHOLOGY. 361 

The movement of the drum membrane inward and its per- 
sistence in this position is favored by the action of the tensor 
tympanic muscle, which by contraction draws the membrane 
inward against the wall of the middle ear. From disuse the 
tendon becomes shortened, this change being aided by the 
inflammatory process. If now the Eustachian tube is re- 
stored to its normal patency, the membrana tympani does 
not assume its correct position, and it may even be impossible 
to replace it by artificial means. Similar changes occur in 
the intratympanic ligaments if the parts are suffered to re- 
main misplaced for a considerable length of time. Of the 
ligaments which bind the ossicular chain together the cap- 
sular ligament of the malleo-incudal articulation suffers the 
most. It may become relaxed, and render displacement of 
the ossicular chain more easy. From the relaxation of this 
ligament the entire drum membrane and the tip of the handle 
of the malleus may be carried directly inward toward the 
tympanic wall by rotation of the malleus upon the axis band. 
The separation of the articular surfaces of the malleus and 
incus prevents the perfect transmission of the aerial vibrations 
to the stapes, and impairment of function results. 

When the hypertrophic process changes to the hyperplastic 
variety the newly deposited connective tissue becomes trans- 
formed, its cellular elements disappear, and are replaced by a 
dense fibrous tissue, which by contraction increases the ten- 
sion in the ossicular chain. 

As to changes occurring in the labyrinth from the process 
within the middle ear, these may depend upon the pressure 
to which the labyrinthine fluid is subjected from the increased 
tension, although this factor exists in the early stages only. 
Labyrinthine complications are not common in the hyper- 
trophic form. The most prominent element in their causa- 
tion is the interference with the labyrinthine circulation. Al- 
though the communication between the tympanic and laby- 
rinthine vessels is not intimate, hypertrophic changes within 
the middle ear exert an influence probably upon the parts 
from which they are separated only by the thin membrane of 
the round window and by the fibres of the annular ligament 
in the fenestra ovalis. A large portion of the venous blood 
from the labyrinth enters the general circulation through 
the vena aquaeductus cochlea?, which leaves the labyrinth 
close to the round window. Flence any increased vascular- 
ity within the tympanum affects the venous flow through this 
25 



362 CHRONIC CATARRHAL OTITIS MEDIA. 

channel both by mechanical pressure and by the change in 
the rapidity of the flow of the blood current. The actual 
communication between the vessels of the middle ear and the 
labyrinth has been demonstrated by Cassebohm,* the anas- 
tomosis taking place at the round window. Buck has dem- 
onstrated a similar communication at the oval window. The 
perforating vessels, which Politzer claims to exist, have already 
been mentioned. While, therefore, the communication may 
not be very direct, a disturbance of the circulation within the 
middle ear, if continued for a long period, must cause changes 
in the labyrinthine blood current, and corresponding changes 
in labyrinthine pressure. 

Symptomatology. — The affection is usually bilateral, al- 
though both organs are seldom involved to the same degree. 
The hearing with which we are endowed is far in excess of 
that necessary to carry on the ordinary vocations of life, and 
one may be unconscious of any impairment of function until 
it exists to a marked degree. When these patients come un- 
der observation they seek relief either on account of the im- 
pairment in function or because of distressing subjective noises. 
The impairment of function is usually intermittent in the early 
stages, the periods during which the hearing seems to the 
patients to be fairly normal having become gradually shorter 
and shorter, until at last they seek relief. This irregularity 
in the occurrence of the symptoms is quite characteristic of 
the hypertrophic variety of inflammation of the middle ear. 
Sudden changes in temperature, indiscretions in diet, or im- 
pairment of the general health cause the local symptoms to 
increase in severity on account of the changes which they 
effect in the mucous membrane. The subjective noises are 
usually more pronounced upon one side than upon the other, 
and the same is true of the impairment in hearing. These 
symptoms may be more marked in the same ear, although 
where the disease has existed for a long time we may find 
that the noises have entirely disappeared from the ear first 
affected, tinnitus being distressing only upon the opposite 
side. Changes in the position of the body may influence both 
the character and the degree of the subjective noises. Quite 
frequently they are only noticed when the patient is lying down. 
They may be synchronous with the cardiac pulsations, or may 
be continuous. They are usually high-pitched, and are vari- 

* Cited by Urbantschitsch, Lehr. der Ohrenheilk., Vienna, 1891, p. 235. 



SYMPTOMATOLOGY. 363 

ously described as singing, hissing, blowing, or whistling 
sounds. These subjective noises may be entirely drowned by 
external sounds. Thus they may disappear in a railway train 
or on a busy thoroughfare, but reappear instantly in a quiet 
room. In the same way external noises affect the hearing to a 
marked degree. Most of these patients are able to hear better 
in a noise than where it is quiet. We may explain this fact 
either upon the hypothesis that the more intense sounds serve 
to set the ossicular chain in vibration, after which sounds of 
less intensity are able to so modify this motion as to be per- 
ceived, although they are unable to overcome intratympanic 
rigidity by themselves, or that loud sounds produce a condition 
of auditory hyperesthesia. 

Where fluid is present in the middle ear, bubbling sounds 
may be complained of upon forcible attempts at clearing the 
nostrils. Snapping or cracking sounds heard in the ear with 
each act of deglutition, due either to the separation of the 
walls of the Eustachian tube at this moment or to the entrance 
of air into the tympanum, is also a symptom often met with. 
Occasionally we may elicit the fact that upon changing the 
position of the head the hearing becomes suddenly impaired. 
This is frequently due to the presence of fluid within the tym- 
panic cavity, the change in position causing it to gravitate to 
the region of the oval and round windows, and thus to impede 
the vibration of the labyrinthine fluid. Occasionally slight ver- 
tigo is complained of. This, however, is not severe, and is usu- 
ally attributable to a sudden change in intratympanic pressure, 
as by auto-inflation, in the act of blowing the nose, aspiration 
of the tympanum by a sudden deep inspiration, etc. In some 
cases, however, vertigo constitutes one of the chief symptoms 
of which the patient complains. The vertigo is then due either 
to a narrowing of the Eustachian tube or to adhesions about 
the round or oval window which interfere with the normal 
labyrinthine pressure. 

Pain is not common in these cases, although, when a sud- 
den stenosis of the tube occurs, the patient may complain of 
occasional neuralgic pains radiating from the pharynx in the 
direction of the ear. In certain rare instances, where the 
chronic inflammation is confined mostly to the region of the 
Eustachian tube, the patient may complain of sharp pain in 
the throat, referred to the region of the lingual tonsil, fre- 
quently more severe upon one side. It is impossible for the 
patient to locate the exact painful point, although frequently 



364 CHRONIC CATARRHAL OTITIS MEDIA. 

it is referred to the posterior pharyngeal folds or to the lymph 
tissue at the base of the tongue. In a large number of these 
cases the pharynx is entirely healthy, and the pain is due to 
the changes in the Eustachian tube. The true nature of the 
affection is frequently discovered accidentally, or not until 
changes within the tympanum have become so marked as to 
demand measures for relief. Most frequently the patient de- 
scribes the sensation as not amounting to actual pain, but that 
the throat feels " rough " or " burns." In other cases the pain 
is intense, rendering deglutition difficult. 

Diagnosis. — A. Physical Examination. — The appearance 
presented by the parts varies according to the extent to which 
the process has advanced. In the early stages, upon inspecting 
the drum membrane, there may be no deviation from the nor- 
mal picture. The most frequent change is a moderate de- 
gree of depression of the membrana tympani, evidenced by 
a foreshortening of the manubrium mallei and exaggeration 
of the posterior fold (Fig. 103). The color of the membrane 
is either normal, or there may be a slight reddening along 
the malleus handle and at the supero-posterior border of the 
membrane, together with a reddish reflex from the internal 
tympanic wall. This last sign is considered particularly im- 
portant by Schwartze, as indicative of the fact that the inflam- 
matory process is still active. The lustre of the membrane is 
usually slightly diminished, while in texture it appears some- 
what thicker than normal. This apparent increase in density 
is usually not general, but is more prominent over certain 
areas. An appearance which is quite characteristic of the 
early stages is the rotation of the malleus 
/^»^L upon its long axis, which, if the membrane 

/wBr4K\ * s at ^ ie same time retracted, causes the 

1|J malleus handle to appear narrower than nor- 

Wj mal. If there is no depression, the rotation 

may cause the manubrium to appear abnor- 

Fig 102 -Rotation mall wide / Fiff I02 ). This change in breadth 

of malleus about J ... 

its long axis in- is due to inequalities in tension of the intra- 
^SatVriu* tympanic ligaments from the inflammatory 
process, which is more pronounced in cer- 
tain portions of the cavity than elsewhere. The presence 
of adhesions or the irregular tumefaction of the membrane 
prevents displacement of the ossicular chain by rotation of the 
malleus about the axis band, but acts in such a manner as to 



DIAGNOSIS— PHYSICAL EXAMINATION. 



36: 



twist the ossicle about its long - axis, turning* one of its pris- 
matic surfaces toward the canal. When displacement inward 
and rotation are both present, a sharp edge of the shaft 
of the malleus is presented to the meatus, thus making the 
shaft appear narrow. The short process is usually more 
prominent and whiter than normal. The position which it 
assumes gives important information as to the direction in 
which rotation has taken place, and whether the increased 
tension lies in the anterior or posterior half of the tympanum. 
The upper portion of the membrane above the short process 
frequently has a crumpled appearance due to localized areas 
of inflammation in the parts beneath. When the disease 
has existed for some time the membrane in this region may 
appear abnormally thin, and over the neck of the malleus may 
be adherent and much depressed. Pressure here may cause 
atrophy of the fibrous tissue, and may give the membrane the 
appearance of having been perforated and having undergone 
cicatrization. In the more advanced cases we find the mem- 
brana vibrans displaced toward the prom- 
ontory, the tip of the malleus frequently 
impinging upon the wall of the middle ear. 
It may be drawn either toward the anterior 
or posterior wall of the tympanum, accord- 
ing to the distribution of the connective 
tissue within the cavity. When displaced fig. 103.— Retraction 
backward and inward, we frequently see a ° f the d . ru ™ mem_ 

1 J brane and adhesions 

tense band running from the short process within the middle 
downward and backward until it is lost ^dle^is Trrow! 
in the posterior margin of the membrane and the supernumer- 
(Fig. 103); so well defined is this that it is distinct. 6 " * 
frequently mistaken for the handle of the 
malleus, which lies in front of it, and is only visible when the 
head of the patient is turned so as to permit the light to be 
directed beneath this fold. Pomeroy has given the name of 
" supernumerary posterior fold " to this band. 

When there is fluid within the tympanum the membrana 
tympani is apparently crossed by a fine line, which marks the 
level of the fluid. This appearance is only presented when 
the drum membrane is not thickened from hypertrophic 
changes. If this has taken place, the level of the effusion 
can not be made out, but the segment below the level of 
the fluid appears more opaque than the part above. The 




366 CHRONIC CATARRHAL OTITIS MEDIA. 

drum membrane over the transudate is of a yellowish tinge. 
the appearance being more marked if the secretion is inspis- 
sated. Occasionally fine bubbles may be seen, appearing as 
iistinct bright points upon the membrana. Any of the above 
appearances should make us suspect the presence of fluid, and 
■any alteration in the picture after inflation confirms the opin- 
ion. If the membrana tvmpani has remained in contact with 
the internal wall of the middle ear for a considerable length 
of time, the pressure may have caused partial absorption of 
the fibrous laver. increasing the transparency of the mem- 
brane in this locality. On the other hand, areas which pre- 
sent evidence of a hypertrophic process are frequently the 
see: :: calcific deposits in the later stages of the disease. The 
development of adhesions between the membrana vibrans and 
internal wall of the middle ear is scarcelv as characteristic of 
the hypertrophic variety of the inflammation as of the hyper- 
plastic, vet we may find this condition present, especially in 
tee region of the umbo, as this is the first point of contact be- 
tween the drum membrane and the external tvmpanic wall, 
the displacement being due both to atmospheric pressure and 
to the action of the tensor tympanic muscle. 

In certain cases, especially where frequent auto-inflation 
has been practiced, the drum membrane becomes much re- 
laxed in the upper and posterior quadrant, and when indrawn 

~:es itself so closely to the bony walls es to permit the intra- 
tvmpanic landmarks in this region, such as the incudo-stapedial 
articulation and the niche of the round window, to be clearly 
made out (Fig. _.: . Such a relaxation of the membrana is 
easily demonstrated if we request the patient to inflate the 
ear bv holding the nose, closing the mouth, and blowing 
forcibly. When this is done the upper and posterior seg- 
ment will be seen to move outward into the canei. while at 
the same time the deeper parts disappear from view. 

The impairment of hearing in these cases disappears to 
an astonishing extent when this relaxation is corrected, but 
may reappear upon deglutition, the air within the middle ear 
being aspirated and the membrane assuming its former posi- 
tion. The presence of adhesions or the condition of relaxa- 
tion just described mav be satisfactorily demonstrated bv 
alternately rarefying and condensing the air in the meatus by 
means of the pneumatic otoscope. The adherent areas do 
not move, while the relaxed Dortions of the drum membrane 



DIAGNOSIS— PHYSICAL EXAMINATION. 367 

are seen to make exaggerated inward and outward excursions, 
according as the air within the canal is condensed or rarefied. 

Anomalies in tension of the intratympanic ligaments are 
easily demonstrated by the pneumatic otoscope. Under ma- 
nipulation the malleus handle, instead of moving directly out- 
ward when the air within the canal is rarefied, will be seen to 
twist upon its long axis, the tip of the manubrium frequently 
remaining fixed, while the short process describes the arc of 
a circle. Clinically this sign is of importance, as it usually 
indicates relaxation at the malleo-incudal articulation, and 
may account for certain subjective symptoms which make 
their appearance only when the patient changes his position 
and suddenly separates the articular surfaces of these ossicles. 

Inflation by the catheter or air bag — preferably the former 
— elicits various auscultatory signs. Evidences of fluid within 
the tympanum have already been mentioned and need not be 
repeated. When the lumen of the tube is narrowed, the air, 
upon entering the middle ear, will produce a high-pitched 
sound on account of the narrowing of the canal. This sound 
may be either moist or dry, according to the stage of the dis- 
ease. When the tube is much narrowed and the walls are 
covered with thick secretion, the air may fail to enter the 
middle ear, and a distinct percussion sound will be recognized 
with each attempt at inflation, as the air impinges upon the 
mass of inspissated mucus at the narrow portion of the tube. 
Prolonged effort will usually dislodge this, after which the 
air will enter the cavity, causing a sudden outward excursion 
of the drum membrane, as evidenced by the peculiar sharp 
click heard as it is driven outward. If the cavity is com- 
pletely filled with fluid, absolutely no sound may be heard. 
It is possible for the adhesions to develop in such a manner 
as to shut off the greater part of the tympanic cavity from 
the Eustachian tube. When this occurs, the air, as it im- 
pinges upon the barrier at the tympanic orifice, will produce 
a distinct percussion note similar to that heard when an ob- 
struction is present at the isthmus of the tube, but not as re- 
mote. Marked relaxation of the drum membrane is reco°> 
nized by the peculiar flapping sound which is heard as the lax 
septum is forced outward. 

Inspection of the membrane immediately after inflation 
will enable us to determine over what areas adhesion has 
taken place between the internal and external tympanic walls. 



368 CHRONIC CATARRHAL OTITIS MEDIA. 

As before stated, adhesion at the umbo is not uncommon, and 
hence inflation may produce little change in the position of 
the membrane, although the hearing may be greatly improved 
by the operation from the re-establishment of equilibrium. 

B. Functional Examination. — The hearing power for the 
voice is considerably reduced. The hearing power for the 
watch or acoumeter is also diminished. The lower tone limit 
is elevated, and where the middle ear alone is involved the de- 
gree of elevation corresponds to the impairment of audition 
for the whisper or for the conversational voice. These cases 
usually hear a whisper relatively better than articulate speech. 
This is due to the fact that the pitch of the whisper of any 
given combination of letters is always the same, while in ar- 
ticulate speech the same word or sentence repeated by differ- 
ent individuals varies greatly, owing to the presence of over- 
tones. The individual quality of the voice depends upon 
these overtones. Hence we find the power of perception for 
the conversational voice varies greatly according to the indi- 
vidual with whom the patient converses, with some the hear- 
ing being but slightly diminished, while with others marked 
impairment is evident. The upper tone limit is either nor- 
mal or slightly lowered. Bone conduction is increased in the 
early stages of the disease, the vibrating tuning fork, placed 
in the median line, being referred to the poorer ear. In ad- 
vanced cases it may be referred to the better ear, and when 
this is the case the prognosis is less favorable. Where the 
upper tone limit is lowered it not infrequently happens that 
the greatest deviation from the normal standard is in the bet- 
ter ear. This is explained upon the theory that the increased 
labyrinthine pressure upon the side first affected has caused 
certain changes to take place in the cortical area specialized 
for the perception of these particular notes. This area re- 
ceives most of its nerve fibres from the ear of the opposite 
side, but a few come from the organ of the same side. The 
influence of the tympanic condition upon the labyrinth of the 
organ first attacked institutes certain cortical changes which 
affect secondarily the nerve fibres derived from the other ear. 
These secondary changes expended upon the receptive mech- 
anism are more rapid than the changes within the middle ear; 
and we find the labyrinthine degeneration on the side last 
involved more marked than in the organ primarily affected. 
It is of importance to recognize this fact as indicative of the 



PROGNOSIS. 369 

progress of the disease, and prompt measures must be insti- 
tuted to curtail the steady advance of the affection. 

Prognosis. — The ultimate outcome will depend upon the 
cause, the social condition of the patient, and the extent to 
which the process has advanced before the patient comes 
under observation. 

When seen in the early stages associated with affections 
either of the nasal passages or of the naso-pharynx, we may 
hope to arrest the disease completely, and in a large measure 
to correct the damage already done. The station in life oc- 
cupied by the patient influences the progress of the disease, 
in so far as it necessitates his exposure to inclement weather, 
physical hardship, sudden changes of heat and cold, and pro- 
longed mental exertion. The age of the patient is also a fac- 
tor. Thus, if the impairment of function is considerable in a 
patient under thirty years of age, we can scarcely hope for 
great improvement except by the employment of the most 
radical means at our command; while the same degree of im- 
pairment met with later in life would be more amenable to 
treatment, since at this period hypertrophic changes in the 
upper air passages are the exception, the tendency being for 
spontaneous absorption to take place, and the affection might 
even improve spontaneously. In any given case where the 
aural lesion is associated with some affection of the upper air 
passages, we can usually promise, by restoring these parts to 
their normal state, to relieve the patient of those sudden fluc- 
tuations in hearing dependent upon vascular disturbances in 
the upper air passages. At the same time the progress of the 
disease will probably be checked, but any marked improve- 
ment in hearing can not be promised if the patient is more 
than thirty years of age, although in many instances the re- 
sults of treatment are exceedingly satisfactory. In young sub- 
jects the changes wrought by thoroughly freeing the upper 
air passages may cause a retrograde process to take place in 
the mucous membrane of the tympanum, and great improve- 
ment may result. The surgeon must be cautious, however, 
regarding the extent of improvement promised. 

Hygienic measures, the observance of which renders the 
patient less liable to colds, must also be considered. In cases 
of long standing the prognosis will depend largely upon the 
presence or extent of secondary labyrinthine involvement, and 
particularly upon the degree to which the ear of the opposite 



370 CHRONIC CATARRHAL OTITIS MEDIA. 

side is affected. Any tendency toward secondary sclerotic 
changes as evidenced by patency of the Eustachian tube, or 
a degree of patency which is abnormal, will also render the 
prognosis more grave. The condition of the tube itself is of 
importance, as it enables us to judge of the changes w r hich 
have probably taken place in tympanic adhesions. If the 
tube is of normal calibre it is probable that these have be- 
come firm, and that the impairment in function depends upon 
this cause. We can scarcely hope to absorb a deposit of long 
standing, and hence our prognosis must be guarded. 

Treatment. — We may divide this into the treatment of 
the upper air passages, the treatment of the Eustachian tube, 
and the treatment of the intratympanic condition. 

Our first care should be to place the upper air passages in 
such a condition as to permit free nasal respiration, and to pre- 
vent as much as possible the venous engorgement of these 
parts from slight exposure to cold. From this we do not 
mean that slight deviation from an ideal condition, anatomic- 
ally speaking, must be dealt with surgically. If the nasal pas- 
sages are free, and no evidence of mouth breathing is present, 
the treatment of this region can in no way improve the audi- 
tory function. In the same way a small amount of lymphatic 
tissue within the pharyngeal vault in patients over twenty 
years of age does not demand removal unless it gives rise to 
some special disturbance. In young subjects, however, I am 
disposed to deal radically with any lymphatic hypertrophy in 
this region if there is the slightest evidence of impairment 
of hearing, since in early life lymphatic tissue is particularly 
prone to vascular changes from comparatively slight causes. 
Adenoid growths, then, should be removed surgically, either 
by the forceps or curette, or absorption effected by the appli- 
cation of chemical agents. Of these, a solution of the nitrate 
of silver, introduced through the anterior nares after the parts 
have been rendered insensitive by cocaine, will be found to 
be effective. A solution of sixty grains of nitrate of silver to 
the ounce may be applied to the part by means of the cotton- 
tipped probe, care being taken not to distribute the solution 
over the walls of the nasal cavity, nor to use it so freely as to 
allow it to pass into the lower pharynx. Hypertrophy of the 
turbinated bodies, if excessive, may be dealt with surgically, 
but usually cauterization with chromic acid will be sufficient. 
Obstructive lesions due to deformity of the septum may be 



TREATMENT— INFLATION. 37 1 

removed either with the saw, trephine, or galvano-cautery, 
as the operator deems most expedient. 

Concerning the removal of the faucial tonsils, it is my be- 
lief that they may cause secondary engorgement within the 
naso-pharynx, and hence, if they are hypertrophied, their re- 
moval is indicated when met with in childhood or early adult 
life. After this period this rule naturally does not apply. 

The Eustachian canal usually requires special measures to 
determine its return to the normal degree of patency. Where 
the obstruction depends merely upon venous engorgement or 
oedema, attention to the upper air passages, together with in- 
flation of the middle ear with air, will be effective without 
any other measures directed to the tube. The beneficial 
effect of inflation upon the calibre of the Eustachian canal 
depends upon the fact that when the normal calibre is re- 
stored for a short time by the passage of a current of air 
which temporarily relieves the engorgement, it gradually re- 
gains its normal patency. The air douche drives the blood 
out of the distended venous channels and permits them to re- 
sume their normal tone, in much the same manner as an 
elastic bandage relieves venous engorgement of the extremi- 
ties. If, however, actual hypertrophy has taken place, stimu- 
lation of the mucous membrane may be necessary in order to 
effect restoration. This is particularly true in instances in 
which excessive secretion is present. The pharyngeal orifice 
of the tube is the part first affected, and the changes are most 
marked in this region. Before attempting any local medica- 
tion, the mucous membrane must be thoroughly cleansed from 
adherent secretion, otherwise our application will have but 
little effect. This may be done by washing out the pharyn- 
geal orifice of the tube with an alkaline solution, such as a 
weak solution of bicarbonate of soda, or the ordinary Dobell's 
fluid, or a solution of boric acid of about twenty grains to 
the ounce, to which may be added half a drachm of Listerine. 
This cleansing is effected by employing a device which con- 
sists of a Eustachian catheter the extremity of which is closed, 
while the curved portion of the instrument is supplied with 
lateral perforations. Fluid injected through this instrument 
does not enter the lumen of the tube, although the trumpet- 
shaped orifice is thoroughly washed and freed from any tena- 
cious secretion. The solution may be injected bv means of 
a common ear syringe inserted into the outer end of the in- 



372 CHRONIC CATARRHAL OTITIS MEDIA. 

strument, or the syringe may be provided with a conical tip 
which fits it exactly. The mouth of the tube may also be 
cleansed by wiping it out with a pledget of cotton, the appli- 
cator being curved like the Eustachian catheter. After thor- 
oughly cleansing the pharyngeal orifice of the tube, it should 
be touched with an astringent solution. A solution of nitrate 
of silver, ten to thirty grains to the ounce, is the application 
most used. In older cases the application of equal parts of 
compound tincture of iodine and glycerin is efficient. Even 
where the tube is involved for a considerable distance beyond 
its pharyngeal aperture, treatment of this region may cause 
absorption of the newly deposited tissue. If this fails, applica- 
tions may be made to the entire length of the canal, either by 
means of stimulating vapors or of medicinal solutions. The 
precise manner of carrying out these measures has already 
been given. Dilatation of the Eustachian canal by bougies is 
exceedingly efficacious where the deposit is of long standing, 
the mechanical stimulation due to the presence of the instru- 
ment within the lumen of the tube causing absorption of the 
new-formed tissue. If the walls of the tube seem much re- 
laxed and the obstruction recurs quickly, although the tube 
may admit the passage of a bougie of considerable size, it is 
well to leave the instrument in position for several minutes to 
restore the normal tone of the tissues. Medicated bougies 
may be used, but their employment is difficult, and presents 
no advantages over topical applications made in the manner 
described under tubal congestion. 

In place of the simple device recommended under " Tubal 
Congestion," for effecting dilatation of the Eustachian tube, 
very satisfactory results may be obtained by the electrolytic 
method, so strongly advocated by Dr. Duel.* By means of this 
method the swollen membrane of the Eustachian tube is restored 
to its normal condition through the influence of the galvanic 
current, the negative pole of the battery being applied directly 
to the inflamed tissues, while the positive pole is applied to some 
neutral point. In order to carry out this plan effectually, it is 
necessary to insulate the catheter through which the bougie is 
passed, to prevent the current from short-circuiting, and also in 
order that the full force of the current may be applied directly to 
the swollen and inflamed membrane. This is effected by wind- 

* New York Medical Journal, January 16, 1897. 



TREATMENT. 



373 



ing an ordinary silver Eustachian catheter with a thin strip of 
rubber tissue, thus forming an insulating coating. An olive- 
tipped metal bougie, preferably made of gold, is then passed 
through the Eustachian catheter, in exactly the same manner as 
has been already described in explaining the technique of the 
simple method. This metallic bougie is connected by means 
of a cord with the negative pole of the galvanic battery. The 
positive pole of the battery is applied at some neutral point by 
means of the flat sponge electrode, the palm of the patient being 
usually selected as the point of its application. The catheter 
is introduced in the ordinary manner and the metallic bougie 
passed into the tube until an obstruction is met with. The gal- 
vanic current is then slowly turned on, being controlled by a 
delicate rheostat, until the milliamperemeter registers from 
three to five milliamperes of current. Slow pressure is main- 
tained on the bougie, and after a short interval the instrument 
will be felt to glide by the obstruction. The instrument is passed 
in this manner throughout the entire length of the tube until it 
is felt to enter the middle ear. The surgeon becomes cognizant 
of this fact by the sensation that the end of the instrument has 
passed into a large cavity and lies perfectly free. He always 
recognizes the fact by remembering the length of the Eusta- 
chian tube and by observing that the bougie has been passed 
for the requisite distance to enter the tympanum, under normal 
conditions. It should be borne in mind that considerable care 
must be taken in carrying out this plan of treatment. It is sel- 
dom wise to use more than five milliamperes of current and 
probably three or four are all that is necessary. The voltage of 
the current must vary with the body resistance in each individ- 
ual case. The voltage should never be more than 40, and usual- 
ly a voltage of 30 is quite sufficient. The galvanic current may 
be generated either by means of a wet or dry cell battery, and 
the ordinary direct street current used for illuminating pur- 
poses may be utilized. When this current is used, proper cau- 
tion must be employed to have a correct transforming apparatus 
for the circuit, so as to be certain that too great a voltage is not 
obtained. It is also important that the rheostat should be very 
delicately adjusted in order that it may control the current per- 
fectly. 

It is difficult to say whether this form of Eustachian bougie 
possesses any great advantage over the simpler method de- 
scribed before. The apparatus is certainly complicated and 



374 



CHRONIC CATARRHAL OTITIS MEDIA. 



somewhat more difficult to manipulate than is the more simple 
device. Regarding the permanency of results obtained, after 
a rather extensive experience with both methods, I am not 
convinced that the results which follow the employment of the 
electrolytic method are more permanent than those which re- 
sult from the use of the simple bougie. 

The injection of fluids into the tube and tympanum is never 
wise. It is true that excellent results have occasionally been 
obtained by this means, but the same object may be accom- 
plished without subjecting the patient to the serious possibili- 
ties which the injection of fluid into the tube entails. Although 
the tympanic portion of the Eustachian canal is inclosed in 
firm, bony walls, it should always be remembered that an ob- 
struction may lie at the tympanic orifice of the tube; and 
although we can not dilate the osseous canal, we may over- 
come an obstruction in the locality above named, and should 
never fail to pass the instrument through the entire length of 
the canal until the tympanic cavity is entered. Relaxation of 
the mucous lining may occur even in this region, and topical 
applications may be beneficial. In many instances an inspec- 
tion of the membrana tympani will reveal the bougie in the 
tympanic cavity. It usually lies behind and a little below the 
short process of the malleus, and by pressure can be made to 
push the drum membrane over it outward into the canal. 

The changes within the tympanum may consist of an ac- 
cumulation of fluid, localized or diffuse hypertrophic changes, 
and adhesions. When fluid is present, its removal should be 
effected through the Eustachian tube if possible. To this end, 
the operation of inflation should be performed with the head 
of the patient inclined a little forward and toward the opposite 
side; the current of air, upon entering the tympanum, will then 
force the fluid through the Eustachian tube into the pharyn- 
geal vault. When this takes place, the sound heard upon aus- 
cultation changes in character from that characteristic of fluid 
within the tympanum to the harsh, bubbling sounds which are 
indicative of secretion at the pharyngeal orifice of the canal. 
Subsequently auscultation reveals an entire absence of bub- 
bling sounds as the air enters the cavity. When removed in 
this manner, the effusion is apt to accumulate a second time. 
To prevent this, it is wise to follow the simple inflation with 
the introduction of a medicated vapor into the middle ear. 
The vapor of compound tincture of benzoin, of eucalyptus, 



TREATMENT— REMOVAL OF FLUID. 375 

menthol, alcohol, ether, iodine, or any other volatile drug which 
possesses mild stimulating properties may be used. The length 
of time during which the application shall be continued will 
depend upon the effect produced; the degree of irritation should 
not be sufficient to amount to actual pain, and the patient 
should be conscious of but a moderate stinging sensation as 
the current enters the tympanum. If the fluid accumulates a 
second time, or if our efforts at evacuation through the tube 
are not successful, the membrana tympani must be incised. 
Only very general rules can be given as to the proper point of 
locating the incision, since the fluid may be encapsulated in 
some of the reduplications of the lining membrane. If the en- 
tire cavity is filled, however, it is best to make the incision in 
the posterior quadrant, dividing the membrane from a point 
just below the posterior fold to the inferior pole, the line of 
section running parallel to the peripheral attachment of the 
membrane. This incision may seem unnecessarily free, but the 
results obtained are much better than where a small opening 
is made, since a large opening permits complete evacuation of 
the fluid, and the parts heal within a few hours, with the devel- 
opment of no cicatricial tissue. A small opening remains patent 
for a longer period and is closed by a deposit of cicatricial tis- 
sue, and the tension of the drum membrane is altered. 

After the membrana tympani has been incised certain meas- 
ures may be necessary to cause the lining membrane of the 
middle ear to return to a perfectly normal condition, and thus 
prevent the reaccumulation of the fluid. These measures con- 
sist in the instillation of astringent solutions through the open- 
ing made, or their injection through the Eustachian tube. The 
former method is decidedly preferable, since the results ob- 
tained are equally good and the discomfort to the patient is 
much less. In certain instances a small amount of fluid remains 
in the cavity after the greater portion has been absorbed; this 
remnant becomes inspissated and adheres closely to the lining 
membrane of the middle ear. Inflation of the tympanum fails 
to remove the collection either on acount of its viscidity, or 
owing to the fact that it lies out of the direct air current. Under 
these conditions the tympanum should be thoroughly washed 
out with boiled water or with Thiersch's solution. This lavage 
may be carried out either through the Eustachian tube or 
through an artificial opening in the membrana tympani. Where 
the object is to cleanse the cavity rather than to medicate its 



376 CHRONIC CATARRHAL OTITIS MEDIA. 

lining membrane, irrigation through the Eustachian tube is 
preferable, since all the recesses of the cavity are reached in 
this way and a considerable quantity of fluid may be used in 
irrigation. In carrying out this procedure the catheter should 
possess a rather sharp curve, and the curved portion should be 
somewhat longer than where the instrument is used for infla- 
tion simply. It should be of such size as to permit its entrance 
into the Eustachian tube for a considerable distance. Very 
little force should be used in injecting the fluid through the 
tube into the middle ear. The injection may be made either 
with the common syringe or with a fountain syringe, the reser- 
voir being raised to such a level as to permit the current to 
pass slowly. In this way any inspissated material is removed 
and the cavity thoroughly cleansed. If proper aseptic pre- 
cautions have been observed, the wound in the membrana tym- 
pani closes within thirty-six hours and usually reaccumulation 
does not take place, while the improvement in function is fre- 
quently considerable. It must be stated that although paracen- 
tesis affords a simple and efficient means of disposing of fluid 
within the tympanum, the collection is exceedingly liable to 
reaccumulate. When this occurs in individuals beyond fifty 
years of age it is unwise to attempt any radical measures to 
prevent reaccumulation of fluid. Incision of the membrana 
tympani in these cases is not painful and affords complete relief 
for periods varying from a few weeks to several months. In 
advanced age the reparative processes of the body are decidedly 
below the normal standard, and very slight causes easily excite 
a middle-ear inflammation. Our efforts, therefore, should aim 
rather to relieve these cases by successive operations than to 
attempt permanently to cure the affection by means which may 
result in a serious middle-ear inflammation. 

Under the impression that the continued pressure of the 
manubrium mallei upon the internal wall of the middle ear 
acted as an exciting cause of the inflammatory process, and 
that the maintenance of the malleus in this abnormal position 
was due largely to shortening of the tensor tympani tendon, 
Weber-Liel * advocated the operation of tenotomy of this mus- 
cle in these cases. If we could separate cases in which the 
inflammatory process depended entirely upon the spastic con- 
traction of the tensor tympani muscle there is but little doubt 

* Monatsschr. fur Ohrenheilk., 1868, Nos. 4 and 12. 



TREATMENT— TENOTOMY OF THE TENSOR TYMPANI. 



377 



that section of the tendon would be followed by complete cure. 
Unfortunately, we have no means of recognizing the fact that 
the process is so limited in extent, and experience teaches that 
by the time the tendon is permanently shortened other portions 
of the middle ear have become affected. The relief obtained 
by the operation was demonstrated by an improvement in the 
ear operated upon and also by a decided improvement in the 
organ of the opposite side, and both Weber-Liel and later Cho- 
lewa * have urged the advisability of the procedure for the 
purpose of preventing the extension of disease to the opposite 
ear. The only fault that can be found with the procedure is 
that it is not radical enough, as it corrects the increase in ten- 
sion at but one point in the ossicular chain. The tendon of the 
tensor tympani may be the locality in which the fibrous 
changes first manifest themselves; but, before this condition is 
recognized, a diffuse hypertrophic process has involved a large 
portion of the membrane lining of the middle ear. It is our 
duty, then, to attempt the correction of this condition as well 
as to direct our measures toward the contracted tendon of the 
tensor. 

In order that the mucous membrane of the tympanum may 
resume its normal condition after hypertrophic changes have 
once taken place, it is necessary to increase temporarily the 
blood supply of the part; in other words, to create artificially 
a moderately acute inflammatory process. The most con- 
venient method of effecting this change is to introduce some 
stimulating vapor through the Eustachian tube into the mid- 
dle ear in the manner described, at the same time removing 
all secondary causes which tend to increase the congestion of 
the tympanic lining. Stimulation by means of fluids injected 
into the cavity should not be undertaken unless an opening 
has been previously made in the membrana tympani. If in 
any given case it seems advisable to inject fluid into the mid- 
dle ear, care must be taken that the instruments employed in 
the operation, as well as the fluid itself, have been thoroughly 
sterilized by heat. I am decidedly in favor, where it is neces- 
sary to use fluids in this manner, to introduce them into the 
tympanum through an opening made in the membrana tym- 
pani for the purpose. 

The choice of medicated vapors in any given case will de- 

* Arch, of Otol., vol. xix, p. 151. 
26 



378 CHRONIC CATARRHAL OTITIS MEDIA. 

pend upon the rules given for their selection for a similar con- 
dition of the Eustachian tube in acute cases. If it seems wise 
to make use of drugs in solution, we should begin at first with 
weak solutions, such as a solution of zinc chloride, two grains 
to the ounce; zinc sulphate, ten grains to the ounce; or nitrate 
of silver, ten grains to the ounce. The strength of the solu- 
tion may be increased until the desired effect is obtained. The 
fluid is introduced through the opening in the membrana tym- 
pani by means of the middle-ear syringe (shown in Fig. 99), 
or by the middle-ear pipette. My experience has been that 
where the process has advanced so far that the introduction of 
vapors does not produce the desired effect, no benefit is gained 
by the injection of fluids. 

Passive motion for securing greater mobility in the ossic- 
ular chain by stretching the newly deposited tissue is not indi- 
cated here, as when the disease is in this hypertrophic stage it 
constitutes an active inflammatory process, which may be 
aggravated by mechanical irritation. The amount of motion 
imparted to the ossicles by catheter inflation preserves their 
motility sufficiently without the employment of other meas- 
ures in this direction. Where the tension of the ossicular chain 
is relaxed, great improvement sometimes follows the use of an 
artificial support, as first suggested by Blake.* This may con- 
sist of a small pledget of cotton inserted in front of the short 
process of the malleus so as to 'press upon it, crowding the 
ossicle backward and inward, or a narrow strip of thin rubber 
may be used, the ends of the strip being brought together and 
grasped in the forceps, and carried into the canal so that the 
convexity of the fold in the strip of rubber rests against the 
short process. Upon removing the forceps the ends of the 
rubber separate, impinging upon the anterior and posterior- 
walls of the canal, while the convex surface of the strip presses 
against the short process of the malleus and crowds the ossicle 
against the incus. 

Failing to check the progress of the disease by any of the 
above measures, or in cases of long standing in which sclerotic 
changes are beginning to take place, as evidenced by marked 
retraction of the membrana tympani, exaggeration of the pos- 
terior fold, and the presence of atrophic areas in the drum 
membrane itself, resort must be had to surgical measures. 

* Arch, of Otol., vol. xxi, p. 166. 



TREATMENT— MECHANICAL SUPPORT. 379 

These comprise tenotomy of the tensor tympani, as already 
mentioned, division of an exaggerated posterior fold (plicoto- 
my), section of intratympanic adhesions binding the ossicles to 
each other or to the tympanic wall, or separation of the drum 
membrane from the internal wall of the middle ear, to which 
it may have adhered; all are of value in special cases. The 
only objection to them lies in the fact that the lesion is sel- 
dom limited to one particular region. The evidence of increased 
tension within the conducting chain is unmistakable, but in 
almost all cases the entire conducting chain is involved, and not 
one particular portion. 

Where the membrana tympani alone is the seat of the ob- 
struction the establishment of an opening through the drum 
membrane is beneficial. Its permanency was long ago shown 
to be the exception rather than the rule, however. If the mem- 
brane is relaxed, its tension may be corrected by applying a 
disk of thin paper over the relaxed area. If the paper disk is 
moistened before it is applied it will maintain its position upon 
drying. My own practice has been, whenever impairment of 
function has seemed to depend entirely upon a middle-ear 
lesion, and when satisfactory improvement has not been ob- 
tained by the employment of measures detailed above, to 
remove the membrana tympani, malleus, and incus, and to 
divide subsequently adhesions about the stapes and about the 
round window. The membrane may be reproduced, but the 
septum thus formed is thin, comparatively insensitive, and pos- 
sesses but slight vitality. Its removal is easily effected a sec- 
ond time, or even a third time if necessary, after which a per- 
manent opening usually remains. The chief value of the pro- 
cedure lies in the fact that it enables us to free the stapes from 
adhesions which may subsequently develop and be a source of 
serious functional impairment. 

The subject of surgical interference in these cases and the 
technique of the various operations is considered in the section 
devoted to the operative surgery of the middle ear. 

Chronic Hyperplastic Otitis Media. 

^Etiology. — The hyperplastic form of tympanic inflamma- 
tion may develop from the form described in the preceding 
section; rarely it follows a purulent otitis media; it may also 
occur as an idiopathic affection. The cases belonging to the 
idiopathic group may follow a severe illness, physical or men- 



380 CHRONIC CATARRHAL OTITIS MEDIA. 

tal exhaustion, and malnutrition. They may depend upon 
interference with the trophic nerve supply of the middle ear. 
Sex exerts a certain influence, females being more frequently 
attacked than males, from which we assume that exposure plays 
but little part in the causation of the affection. A severe men- 
tal shock, such as fright, may exert a causative influence in 
the disease under consideration. The influence exerted by any 
abnormal condition in the upper air passages is usually of but 
slight importance except in those cases which follow the hyper- 
trophic form of inflammation. The disease may attack both 
ears, or the organ of but one side may be affected. When the 
condition is present upon both sides the organ last affected may 
become involved only after many years, and it frequently hap- 
pens that patients do not discover any impairment of hearing 
until the previously healthy ear is affected, when examination 
reveals marked impairment in the hearing power of the opposite 
side. The affection is to an extent hereditary, especially in 
those cases of neuropathic origin, although this factor in causa- 
tion is probably much overrated. Hyperplastic inflammation 
of the middle ear is most common between the ages of forty 
and fifty, although it may develop in early adult life, or even in 
childhood. Its development in advanced age is rare. 

Pathology. — The changes which the mucous membrane 
undergoes have already been touched upon. They consist of 
an increase of fibrous tissue in the mucous membrane lining 
the tympanum, which becomes firm and dense in consistency 
and less vascular. The augmentation of the fibrous elements 
causes atrophy of the glandular structures and diminished secre- 
tion results. As the tissues undergo this fibrous metamorpho- 
sis they become dense, and the normal ligaments which support 
the ossicles within the middle ear and which bind them to one 
another are shortened. In addition to these changes in the lin- 
ing membrane, a certain amount of new tissue is deposited, 
forming bands of adhesions between the ossicles and the internal 
wall of the tympanum, displacing the ossicular chain and bind- 
ing it firmly to the osseous walls of the middle ear. The mem- 
brana tympani is usually unchanged in the early stages, but 
by stretching may become atrophic in places, or by prolonged 
contact with the internal wall of the tympanum may become 
adherent to it. The hyperplastic changes are usually more 
marked in the region of the oval or the round window, in the 
former position binding the stapes firmly in the pelvis ovalis; 



PATHOLOGY. 381 

while occurring in the latter locality they prevent free oscilla- 
tion of the membrana tympani secundaria. When the stapedio- 
vestibular ligament is involved, the foot plate becomes firmly 
fixed in the foramen ovale, and in cases of long standing bony 
sclerosis may occur. The tendon of the stapedius muscle with 
the mucous folds which commonly invest it undergoes shorten- 
ing, causing displacement and fixation of the stapes, the poste- 
rior cms being drawn toward the adjacent wall of the oval 
niche, to which it contracts adhesions. All of these changes 
about the oval and round windows may occur without displace- 
ment of the membrana tympani, or without giving rise to any 
changes discoverable upon ocular inspection. 

When the upper part of the cavity is much involved, the 
entire ossicular chain is frequently displaced inward, dimin- 
ishing the breadth of the tympanic cavity without rotation of 
the ossicles about the axis band. In other cases the fibres 
may be so disposed as to draw the tip of the manubrium in- 
ward, exaggerating the anterior and posterior folds and giv- 
ing rise to a picture similar to that seen when the Eustachian 
tube is closed, the handle of the malleus lying almost hori- 
zontal, the short process being prominent. 

The changes may involve the upper part of the cavity pri- 
marily, and lead to rotation of the malleus about its long axis, 
increasing or diminishing its apparent breadth, as observed in 
speculum examination. A process sclerotic from the first does 
not give rise to the crumpled appearance in the membrana 
flaccida mentioned in the preceding chapter; this condition, ac- 
cording to Walb,* is characteristic of a secondary sclerosis fol- 
lowing hypertrophic changes. The same may be said in general 
of most of the changes recognizable in otoscopic examination, 
marked displacement of the ossicular chain usually indicating 
a preceding hypertrophic process. 

The inflammatory process is not limited to connective tissue 
alone, but may involve the osseous structures as well. When 
this occurs the shaft of the malleus may present irregularities 
due to localized periostitis. 

Labyrinthine involvement of various grades may occur 
even in the early stages. It may be so slight as to escape no- 
tice or in advanced cases so extensive as to play an important 
part in the impairment and perversion of the function. When 

* Schwartze, Handb. der Olirenheilk., Leipzig, 1893, vol. ii, p. 19S. 



382 CHRONIC CATARRHAL OTITIS MEDIA. 

both ears are affected the labyrinthine involvement is frequently 
more marked upon the side last involved. 

The changes occurring in the Eustachian tube result in an 
undue patency of the canal; this condition exposes the parts 
within the tympanum to traumatism from violent efforts at 
coughing, sneezing, or clearing the nose. The tubal muscles 
are also involved, becoming atrophic quite early in the course 
of the disease. 

Otosclerosis, Rarefying Osteitis of the Labyrinthine Capsule. — 
In addition to the secondary changes in the labyrinth, such as 
fixation of the head and foot plate of the stapes, consequent 
to middle-ear changes, we sometimes find changes occurring 
in the bony labyrinth, with little or no change in the middle 
ear. These changes in the labyrinth consist in the development 
of new osseous tissue within it, usually in the vicinity of either 
the oval or the round window. The process constitutes a true 
osteitis. The new bony deposit may either be in the vestibule — 
that is, beyond the foot plate of the stapes — or it may be in 
the stapedio-vestibular ligament, or may invade the foot plate 
of the stapes, the ligament and the oval window itself. Some- 
times these deposits occur in the region of the round window, 
almost completely closing this opening. In some instances, 
where this condition is present, the drum membrane may 
present absolutely no deviation from the normal standard. 
The Eustachian tube is entirely patent, and both ocular in- 
spection and auscultation reveal nothing abnormal about the 
middle ear. 

Symptomatology. — In the early stages the affection is so 
insidious that considerable damage occurs before the atten- 
tion of the patient is directed to the ears. Subjective noises 
are present in a large number of instances, and often cause 
more distress than the impairment of hearing. They appear 
early in the affection, as a rule, and increase in severity as the 
disease progresses. Slight attacks of giddiness may also occur 
in the early stages, but are usually attributed by the patient 
to a disturbance of digestion or to some irregularity in the habit 
of life. The impairment in hearing is at first moderate, and 
its advance is so gradual as not to be noticed by the patient 
until both organs are involved, or until one is seriously affected. 
Pain of neuralgic type and intermittent in character is occa- 
sionally present in these cases. The attacks of pain are usually 
of but short duration, the patient complaining that several times 



SYMPTOMATOLOGY. 383 

during the day there has been a sudden sharp pain in the throat 
radiating toward the ear. Occasionally a dull headache referred 
to the orbital region of one or both sides is complained of. 
This is apt to persist for a considerable length of time, and the 
patient feels entirely unfitted for any kind of mental or physical 
labor, the entire sensorium being to an extent blunted. This 
dull mental condition causes considerable depression, which in 
turn aggravates both the impairment in function and the dis- 
tress caused by the tinnitus. As the result of this impairment 
of the general nervous tone, the condition of the patient may 
approach that seen in melancholia, and in certain instances the 
patient may develop a suicidal mania and attempt to take his 
own life rather than bear the distress which the tinnitus occa- 
sions. The perverted mental condition affects the general nu- 
trition of the body, and the patient loses flesh, becomes anaemic, 
and to all appearances is suffering from some severe con- 
stitutional malady, producing pronounced neurasthenic symp- 
toms. 

In the more advanced stages the impairment of hearing is 
•of a somewhat peculiar type, in that it undergoes marked 
changes from no other assignable cause than the effort made 
by the patient to understand conversation. When attention 
is not particularly drawn to the fact that the power of audi- 
tion is being tested, the hearing may be fairly good; the mo- 
ment, however, the patient is conscious that a test is being 
made of his ability to hear certain sounds, the impairment in- 
creases to a marked degree, and words which a few moments 
before have been understood perfectly well are not heard. The 
fades which these patients present is somewhat characteristic, 
being indicative of intense mental strain, clue probably to their 
efforts to conceal their affliction. 

It must be admitted also that the constant effort to hear 
which these patients exert is responsible for the condition of 
impaired nervous tone from which they suffer. The fatigue 
of the higher centres from this constant strain can not fail 
to exert a profound influence upon the nerve elements and 
lead to nerve exhaustion. 

A curious mental perversion which many exhibit, in addi- 
tion to the depression of spirits already spoken of, is the feeling 
of suspicion with which they regard even their most intimate 
acquaintances. As they can not understand general conver- 
sation, the patients in whom the neurotic tendency is pro- 



384 CHRONIC CATARRHAL OTITIS MEDIA. 

nounced seem to feel that any remark made in a low tone 
refers to their condition and is a direct reflection upon them. 
For this reason many become averse to performing their social 
duties and isolate themselves as completely as possible. It is 
hardly necessary to state that this action tends rather to increase 
than to relieve the functional impairment. 

After the disease has persisted for a long time the tinnitus, 
which was at first distressing, may become less marked, or 
may disappear completely. When both ears are involved, the 
tinnitus is often more severe upon the side last affected. This 
is undoubtedly due to the fact that labyrinthine changes upon 
the side primarily affected have gone on to such a degree that 
the portion of the labyrinth which normally responds to sounds 
similar in character to the tinnitus from which they formerly 
suffered has been completely exhausted, and no longer reacts 
to stimulation due to increased pressure. 

Diagnosis. — A. Physical. — These cases present, upon ex- 
amination, appearances which vary widely, according to the 
course which the affection has pursued. When the process has 
been sclerotic from the first, the ear may present no changes 
upon inspection. The position of the light reflex may be 
normal; the lustre of the membrane may be preserved; the 
density may be uniform, and no deviation from the normal 
position may be recognizable. Under these conditions we are 
usually correct in assuming that the process has been of the 
hyperplastic type from its incipiency, and that the deposit of 
fibrous tissue has taken place chiefly about the oval and round 
windows. Occasionally inspection of the inner extremity of 
the osseous meatus will reveal a slight change in color, the cutis 
being of a somewhat pinkish tinge. This is indicative of the 
presence of an inflammatory process within the tympanic cavity, 
and shows that the disease is still in an active stage. Where the 
membrana tympani has become slightly atrophic we may ob- 
serve a similar congestion affecting the inner tympanic wall, 
which imparts a slightly pinkish tinge to the otherwise normal 
membrana tympani. The thinning of the membrana, particu- 
larly of the upper and posterior segment, may enable us to see 
the long process of the incus, the incudo-stapedial articulation, 
and stapedius tendon in their normal position (Fig. 95). In 
other instances we may have slight sinking inward of the mem- 
brana tympani, with rotation of the malleus about its long axis. 
If rotation has occurred from behind forward, the shaft of the 



DIAGNOSIS— PHYSICAL EXAMINATION. 



385 




malleus appears somewhat broader than normal, and of a dead- 
white color (Fig. 102). This change in color is due to atrophic 
changes in the overlying fibrous layer. When rotation takes 
place in the opposite direction we usually have considerable 
retraction of the membrana tympani, exaggeration of the ante- 
rior and posterior folds, and the fundus of the canal assumes 
a more circular contour (Fig. 104). In these cases a sharp 
edge of the prismatic shaft of the manubrium ____^ 

is presented to view, which causes the shaft 
to appear narrower than normal. In cases of 
long standing, especially if met with in ad- 
vanced life, the inflammatory process may 
have induced certain changes in the perios- 
teal covering of the manubrium mallei, as the ^^ractioi^of ^the 
result of which irregularities in outline appear drum membrane 

,1 1 r, m. ,., -x • r 1 and slight narrow- 

upon the shatt. I hese are really calcific de- ing f the malleus 
posits in this periosteal covering, and are wor- handle from rota- 
thy of note, as they suggest the possibility of 
similar deposits within the tympanic cavity in the neighborhood 
of the oval or round window. Where the degree of depression 
of the drum membrane is considerable the process has usually 
supervened upon preceding hypertrophic changes. The in- 
creased tension to which the membrana tympani has been sub- 
jected has resulted in an attenuation of its fibrous layer, and in- 
spection of the underlying intratympanic parts is possible. In 
addition to these changes, it is not uncommon to find the drum 
membrane adherent in places to the inner wall of the tym- 
panum, particularly at the umbo. The position of the light 
reflex varies with the degree of inclination of the membrana 
to the walls of the canal, but is of little diagnostic impor- 
tance. As mentioned before, changes in the membrana flac- 
cida are of diagnostic importance in determining the devel- 
opment of disease upon a preceding hypertrophic process. 
When this has occurred, the membrana flaccida presents a 
crumpled appearance, and may be adherent to the neck of 
the malleus. In cases that have been hyperplastic from the 
start Shrapnell's membrane presents no such changes, but pre- 
serves its normal conformation, although its color may be 
slightly lighter than in health. Deposits of lime salts in the 
membrana tympani are seldom seen, although, when the con- 
dition is met with in advanced life, such deposit may be pres- 
ent along the annulus tympanicus. 



386 CHRONIC CATARRHAL OTITIS MEDIA. 

B. Functional Examination. — The hearing power is dimin- 
ished to a varying degree for both whispered and spoken words. 
The degree of impairment for sharp noises, such as the tick 
of a watch or the sound of an acoumeter, varies with the amount 
*of labyrinthine involvement present, and hence constitutes an 
unsafe test for estimating the power of audition when the case 
first comes under examination, or subsequently for determina- 
tion of the improvement which has followed as the result of 
treatment. Quite frequently the hearing power for the watch 
and the voice will be disproportionate. The watch may not be 
heard at all, while spoken or whispered words may be heard for 
a considerable distance, and the patient may consider this ear 
better than its fellow, although upon the opposite side the watch 
may be heard at a considerable distance, while the voice can 
not be understood as well as on the other side. This depends 
upon the fact that the labyrinthine changes impair the hearing 
for sharp sounds, such as the tick of a watch, since these lie in 
the upper portion of the musical scale, while that portion of 
the musical register which is made use of in conversation lies in 
the lower portion of the scale, and may be perceived, although 
considerable labyrinthine involvement is present. Interference 
with the conducting mechanism, on the other hand, impairs the 
hearing first for the lower notes, and hence conversation is 
heard more poorly in the ear possessing the most marked tym- 
panic involvement. 

The lower tone limit is considerably elevated. Bone con- 
duction is increased where the changes are confined to the 
middle ear. The fork placed upon the vertex is referred to 
the poorer ear provided only middle-ear changes have taken 
place, but where serious labyrinthine changes have occurred 
it may be referred to the better ear. This is not invariable, 
however, for, as already stated in pathology, changes in the 
perceptive apparatus in the ear last involved often progress 
with great rapidity, becoming in a short time more extensive 
than in the organ first affected. When this is the case the 
vibrating tuning fork applied over the median line of the skull 
may be referred to the ear which was first affected, although 
this may be the poorer ear. This should not mislead the ex- 
aminer into believing that the trouble upon the side to which 
the fork lateralized is entirely free from labyrinthine trouble. 
Increased tension in the conducting system may be sufficient 
to produce this phenomenon, even when the labyrinth is in- 



DIAGNOSIS— FUNCTIONAL EXAMINATION. 387 

volved to a considerable extent. Absolute bone conduction 
may vary according to the age of the patient as well as with 
the degree to which the labyrinth has suffered; hence this 
test yields but little information. When absolute bone con- 
duction is exaggerated we are justified in assuming that no 
serious labyrinthine involvement exists. In cases occurring 
in advanced life, however, the labyrinth may be intact, although 
sound conduction through the cranial bones is below normal. 

Of much more value than absolute bone conduction is the 
relative duration of sound perception through the solid media 
as compared with the period during which the same sound is 
heard through the air. In this manner we are able to esti- 
mate with considerable certainty the amount of impairment de- 
pending upon the labyrinthine changes, as distinguished from 
that caused by the intratympanic lesion. In a given case, where 
whispered words are but poorly perceived, if the reversal of 
the relation between air and bone conduction exists for a fork 
making 512 V. D. or for a fork of the next higher octave, we 
are warranted in assuming that most of the impairment depends 
upon intratympanic changes. With the same degree of func- 
tional impairment, if this reversal should occur only for a fork 
making 64 V. D., while for the octave above this the air con- 
duction was better than bone conduction, we should assume 
that serious labyrinthine changes had taken place. 

The determination of the upper tone limit is of great value 
in these cases in confirming the fact that the labyrinth is 
involved. The first turn of the cochlea perceives the highest 
notes of the musical scale, and secondary labyrinthine degen- 
eration should be characterized by a lowering of the upper 
tone limit, as this portion of the cochlea is in the most imme- 
diate relation to the middle ear and is the part which suffers 
first in secondary labyrinthine affection. When functional ex- 
amination shows a defect at the upper portion of the scale, per- 
sisting after anomalous tension has been corrected by inflation, 
labyrinthine involvement is almost certain. A history of attacks 
of vertigo is confirmatory of this opinion. 

Where we have to deal with a true otosclerosis or osteitis, 
involving the labyrinth primarily, the differential diagnosis may 
only be made by observing the case for a considerable period 
of time, and also by following closely the effects of treatment. 
The deposit of new bony tissue in the labyrinth in the very 
early stages gives rise to exactly the same phenomena upon 



388 CHRONIC CATARRHAL OTITIS MEDIA. 

functional examination as does some obstruction to sound con- 
duction in the middle ear. When, however, a careful physical 
examination shows that the middle ear is apparently normal, 
and, in spite of this, there is impairment of hearing, with eleva- 
tion of the lower tone limit, normal or increased bone conduc- 
tion, and a normal upper tone limit, the surgeon should always 
suspect the possibility of a beginning primary sclerotic process 
in the labyrinth. An hereditary history of deafness should al- 
ways be regarded with suspicion, in cases presenting these 
symptoms. 

Prognosis. — Hyperplastic changes within the tympanum 
constitute an affection of the gravest character as regards the 
integrity of function, and one which is less amenable to treat- 
ment than all other aural diseases. The usual course is steadily 
progressive, although the affection may remain quiescent for a 
long period of years. 

Knowing this fact, it is difficult to estimate the value of treat- 
ment in any given case, the apparent improvement being pos- 
sibly due to a period of spontaneous quiescence. When seen 
in the early stages, and affecting but one side, a fairly favorable 
prognosis may be given. When both organs are affected it 
will be impossible to restore either ear to a perfect condition. 
The most we can hope for is a slight improvement in one or 
both, and to check permanently the progress of the affection. 
Aside from treatment, the environment of the patient or the 
occurrence of any severe illness affects the progress of the aural 
condition to a marked extent. A severe illness, prolonged 
physical exertion, overwork, or anxiety — all tend to hasten its 
advance. From the fact that many cases are of neuropathic 
origin, particular attention must be paid to the habit of life. 
All excesses, either of the table or undue indulgence in tobacco 
or alcohol, should be avoided, and the preservation of a normal 
condition of the larger viscera and of the prima? vise must be 
insisted upon. Climate is a factor in prognosis only to the ex- 
tent to which it causes impairment of the general health. Since 
a dry atmosphere and an equable temperature are most con- 
ducive to a normal condition of the upper air tract, the disease 
perhaps progresses less rapidly in regions where these climatic 
conditions are found. I am inclined to believe, however, that 
the influence of climate has been much overestimated. The 
age at which the affection develops may influence its progress. 
When occurring late in life, its advance is usually slow unless 



TREATMENT— PASSIVE MOTION. 



389 



aggravated by some cause, such as a severe intercurrent dis- 
ease, mental strain, or prolonged physical exertion. Its ap- 
pearance at the menopause is not uncommon, and our prognosis 
in incipient cases met with at this period of life should be ex- 
ceedingly guarded. 

Treatment. — The two conditions with which we have to 
deal are those resulting from the connective-tissue deposit 
within the tympanum and the secondary labyrinthine changes. 
The intratympanic condition being one essentially of rigidity 
of the ossicular chain, our first efforts are to relieve this ab- 
normal tension. When seen early it may be possible to effect 
absorption of the newly deposited tissue by stimulation of the 
mucous lining of the tympanum; this is done by inflation by 
means of the catheter, making use of some of the stimulating 
vapors already mentioned in the treatment of hypertrophic in- 
flammation. By inflating with considerable force we may be 
able to rupture recent adhesions and thus relieve the conducting 
mechanism, or the bands 
may be stretched sufficient- 
ly to permit increased mo- 
bility in the ossicular chain. 
The Eustachian tube sel- 
dom requires attention, al- 
though the exercise of the 
tubal muscles, either by 
gargling or better by mas- 
sage by means of the Eusta- 
chian bougie, may correct 
the changes which have 
taken place here. Accord- 
ing to some authorities, this 
massage also exerts a favor- 
able influence upon the 
tensor tympani muscle and 
prevents its atrophy and 
subsequent shortening. To 
massage the tube in this way the bougie is introduced as far 
as the isthmus and then moved rapidly inward and outward 
for a few seconds. Passive motion by means of Siegel's oto- 
scope affords us a means of combating the adhesions. The 
instrument should be introduced into the meatus, care being- 
taken that it fits the lumen air-tight. The air is then alter- 




Fig. 105. — Delstanche's masseur. 



390 



CHRONIC CATARRHAL OTITIS MEDIA. 



nately rarefied and condensed in the external auditory canal, 
imparting to-and-fro movements to the drum membrane and 
attached ossicula. The masseur of Delstanche (Fig. 105) 
acts upon the same principle. Cases have been reported where 
rupture of the membrane has taken place by the violent use 
of these instruments; this seems hardly probable, however, 
if even an ordinary amount of care is taken in their manipu- 
lation. In the same direction manipulation of the parts at 
the hands of the patient has been tried, in some cases with 
success. The method was first devised by Hommel and con- 
sists in pressing the tragus backward over the external meatus 
until this is completely closed, thus condensing the air in the 
canal. By now alternately increasing and relaxing the pressure 
upon the tragus the density of the air in the canal is augmented 
or reduced and the drum membrane made to perform inward 
and outward excursions. 

In a general way, I am rather inclined to believe that 
the employment of any instrument for the purpose of pneu- 
mo-massage is contraindicated in these cases. A little thought 
will enable us to easily understand that the drum membrane, 
being the most elastic structure upon which the masseur 
acts, will be the most easily influenced by changes of pres- 
sure within the external auditory meatus. While the object 
of pneumo-massage is to increase the motility of the ossi- 
cles, its real effect, if employed for any length of time, will 
be to cause a relaxation of the drum membrane, especially 
in the posterior quadrant. The intratympanic adhesions, con- 
sisting as they do of dense bands of connective tissue, will be but 
little influenced by the rarefaction of air within the canal. The 
more elastic drum membrane, however, presenting as it does a 
large surface capable of expanding as the pressure within the 
tympanum becomes relatively increased, must certainly become 
stretched if the air within the external auditory meatus is re- 
peatedly rarefied. Any apparatus for pneumo-massage, there- 
fore, can not improve the patient, but must, in very many in- 
stances, cause an aggravation of the symptoms. I have been 
convinced of this by observing the effect of pneumo-massage in 
quite a number of cases. Massage by Hommel's method will 
probably do no harm, but it is doubtful whether it ever does 
any good. I do believe, however, that a certain amount of bene- 
fit may be obtained, in rare cases, by a thorough massage of the 
muscles of the neck overlying the Eustachian tube. The bene- 



TREATMENT— MASSAGE— PASSIVE MOTION. 391 

licial results secured are probably due to the circulatory changes 
induced in the mucous membrane lining the tube and mid- 
dle ear. 

The various instruments recommended in these cases for 
mobilization of the ossicles by " vibratory massage " deserve 
only a passing notice. Many instruments have been construct- 
ed for this purpose and all have failed to produce the improve- 
ment desired. In many cases the use of these instruments has 
been followed by a marked diminution in the power of audition 
and an increase in the intensity of the subjective noises due to 
an overstimulation of the auditory nerve. 

Politzer has devised a method for maintaining a constant 
negative pressure in the meatus by the use of a conical plug 
of cotton which is impregnated with cocoa butter. This plug 
is inserted into the canal at night, and, in virtue of its oleagin- 
ous composition, absorbs the air contained within the meatus, 
thus causing the membrana tympani to move outward under 
the action of the air within the middle ear. I have had no per- 
sonal experience with this plan, but in cases where it has been 
tried I have failed to see any benefit. It is certainly inferior 
either to Hommel's method or to systematic manipulation with 
the Siegel otoscope. 

Lucae * has met with considerable success in applying pas- 
sive motion to the ossicular chain by means of the pressure 
sound. The device consists of a small tube through which a 
rod terminating in a cuplike extremity passes. The other end 
of the rod lies within the tube and rests upon a small spiral 
spring the tension of which is regulated by a small screw on the 
handle of the instrument. In use, the cup-shaped extremity 
is applied to the short process of the malleus, over which it 
fits, the manipulation being effected under illumination. Pres- 
sure inward upon the handle of the instrument is communicated 
to the ossicular chain, the degree of pressure depending upon 
the tension of the spring. By pressing the handle of the in- 
strument inward and then relaxing the pressure, the entire 
ossicular chain is alternately forced inward and then allowed 
to resume its former position through its own elasticity. It 
has been demonstrated that pressure exerted at the short proc- 
ess of the malleus is communicated directly through the incus 
to the foot plate of the stapes, and from this to the labyrinth. 

* Arch, fiir Ohrenheilk., vol. xxi, p. S4. 



392 



CHRONIC CATARRHAL OTITIS MEDIA. 



The advantage of the device over an ordinary probe consists in 
affording us the means of alternately increasing and diminish- 
ing this tension without removing the instrument from the 
short process of the malleus, as its continual reapplication would 
be attended by considerable pain. In my practice a modified 
manipulation similar to this has not been attended by favorable 
results. 

The use of the instrument of Lucae is somewhat painful. 
Many patients, especially in private practice, would object to 
the measure, and it has never seemed that the results obtained 
warranted the infliction of so much discomfort. The. length of 
time during which this method of treatment should be carried 
on must vary with the individual cases. 

It has never seemed to me wise to give an absolutely un- 
favorable prognosis in any case where the lesion was confined 
mostly to the middle ear without trying the effect of stimula- 
tion of the lining membrane by means of vapors for a period 
of four to six weeks, the inflation being performed at first on 
alternate days and the interval gradually increased to three or 
four days. In addition to the inflation, passive motion by 
means of the Siegel otoscope may be employed, or, if it seems 
desirable, the use of the pressure sound. At the end of this 
period, if no improvement results, surgical measures are im- 
perative, and, unless the degree of improvement is considera- 
ble, the same advice should be given. During this period the 
observance of the ordinary hygienic rules should be insisted 
upon; but attention to the upper air passages is seldom fol- 
lowed by marked improvement, unless there have been symp- 
toms referable to these parts demanding treatment for their 
relief. 

The surgical measures to be adopted in these cases will 
depend upon the physical condition present. It may be suf- 
ficient to divide tense bands which may be seen by ocular 
inspection, such as an excessive deposit of connective tissue in 
the posterior fold, or adhesions between the tip of the manu- 
brium and the internal tympanic wall. As mentioned in a pre- 
ceding chapter, however, it is impossible to assert that the in- 
crease in tension is due to the presence of adhesions in any one 
particular locality. The procedure, therefore, which seems most 
wise is at first an exploratory myringotomy under strict anti- 
septic or aseptic precautions. A large flap involving the en- 
tire postero-superior segment of the membrana vibrans should 



TREATMENT— OPERATION. 393 

be turned downward and forward, the intratympanic structures 
inspected, and the degree of mobility of the stapes determined 
by means of a delicate probe introduced through the opening. 
This procedure can be conducted under cocaine anaesthesia and 
tests can be made of the hearing at various stages of the opera- 
tion. Occasionally the artificial opening into the tympanum 
may improve the hearing power to a remarkable degree; if this 
does not occur, disarticulation at the incudo-stapedial joint 
should be the next step. If the stapes is movable, the hearing 
will now be improved; if this ossicle is fixed, however, but slight 
improvement will be noticed. The stapes must then be freed by 
division of the stapedius tendon and of any adhesions lying in 
the oval niche, in the manner to be described in the chapter on 
operative procedures within the tympanum. After the adhe- 
sions have been severed as completely as possible passive mo- 
tion should be employed, the stapes being crowded first upward, 
then downward, then forward, and finally backward by means 
of a delicate steel probe the extremity of which is protected 
with a small cotton pledget firmly wound upon it. The condi- 
tion of the round window should also be investigated and adhe- 
sions in this region severed with an angular knife. If the degree 
of fixation is extreme it may be wise to attempt extraction of 
the stapes, although the results obtained are not perfectly satis- 
factory, and the author prefers to remove the malleus, incus, 
and drum membrane, leaving the stapes in an easily accessible 
position, so that subsequently mechanical mobilization may be 
effected if fixation occurs again at any future time. I am 
aware that this method has been criticised, but it possesses the 
advantage of freely exposing the parts and enabling us to make 
successive efforts at freeing the stapes rather than necessitating 
the completion of all operative interference at the time of the 
first operation. Certainly in my own practice results have been 
better where this plan has been followed than where stapedec- 
tomy has been performed, and the opening in the drum mem- 
brane closed as quickly as possible. The operative technique 
and the results obtained will be detailed in a later chapter, 
devoted to the subject of middle-ear operations. 

The measures herein enumerated constitute the most effi- 
cient means at our disposal for dealing with the intratympanic 
conditions. When the labyrinth is involved to any extent oper- 
ative interference is contraindicated, since the cases do not im- 
prove after such procedures, but are frequently rendered worse. 
27 



394 CHRONIC CATARRHAL OTITIS MEDIA. 

The extent of labyrinthine involvement in any given case is 
determined bv the degree to which the upper tone limit is low- 
ered and bv discovering the upper limit in the musical scale 
at which the normal ratio between air and bone conduction is 
reversed. With a marked lowering of the upper tone limit and 
an inversion of the ratio between bone and air conduction for 
the low notes alone, in cases where the impairment of hearing 
is so marked that whispered words can not be distinguished 
at a distance of two or three feet from the ear. the labyrinthine 
feature is so prominent as to positively contraindicate opera- 
tive interference upon the tympanum. The result of treatment 
for the labyrinthine affection is usually less favorable than in 
primary labyrinthine disease. At the same time, we are at least 
justified in making the attempt to remove the difficulty. 

The drug, the administration of which is followed by the 
best results, is undoubtedly pilocarpine. The physiological 
action of the drug increases the vascularity of the labyrinthine 
tissues, at the same time augmenting the activity of the cuta- 
neous and salivary glands. From the increased blood supply 
any excess of labyrinthine fluid is abstracted from the bony 
cavity which contains it. entering the general circulation and 
subsequently being eliminated in the cutaneous or salivary 
secretions. The increased vascularity may also cause the resorp- 
tion of newly deposited tissue, provided the deposit is not too 
old. Formerly the drug was administered by hypodermic injec- 
tion. This, however, renders it necessary for the patient to 
give up a considerable portion of each day to the treatment, 
and in many instances this can not be done. For the last two 
years I have administered it by the mouth, beginning at first 
with doses of one eighth to one sixth of a grain two or three 
times daily, the amount being gradually increased until a mod- 
erate physiological effect followed each exhibition. It is only 
necessary to warn the patient to exercise caution against ex- 
posure to draughts for the period of an hour and a half follow- 
ing each administration of the remedy. In those cases where 
the vocation of the patient necessitates absence from home for 
the entire day one dose may be administered early in the morn- 
ing immediately upon rising, while the second may be given 
upon retiring at night. In this way the patient is able to pro- 
tect himself sufficiently against undue exposure, and by follow- 
ing this plan no untoward symptoms have resulted. Profuse 
salivation need not be produced, nor need the cutaneous secre- 






TREATMENT— INTERNAL MEDICATION. 



395 



tion be increased to such a degree as to be unpleasant. A 
moderate increase in the moisture of the skin and in the amount 
of saliva is an evidence that the drug is producing the desired 
effect, and the patient learns after a short time to so grade the 
dose as to obtain the desired action. No results can be hoped 
for unless the plan is persisted in for a considerable period — 
certainly for two months — at the end of which time, if the slight- 
est improvement is manifested, it should be continued for twice 
or thrice this period. 

According to Kosegarten,* the remedy exerts a beneficial 
action upon the mucous membrane of the tympanum also, caus- 
ing an absorption of newly deposited connective tissue. It 
is possible to observe a congestion of the tympanic lining if 
the patient is examined one or two hours after the adminis- 
tration of the drug. Politzer advocates the local application 
of the muriate of pilocarpine to the mucous membrane, a few 
drops of a two-per-cent solution being injected through the 
Eustachian catheter. Personally I have no experience with 
this plan. 

In cases of hyperplastic inflammation occurring in advanced 
life the auditory nerve may be found in a condition of torpor. 
Here strychnine may be given with advantage, the amount 
being gradually increased to the full physiological limit. This 
drug is also valuable in cases with pronounced neurasthenic 
symptoms. For the relief of distressing tinnitus which persists 
in spite of all local treatment directed toward the middle ear 
dilute hydrobromic acid will sometimes be found efficacious. 
This is to be given well diluted, in doses of thirty minims, three 
or four times daily. The question of subjective noises will be 
more fully dealt with under diseases of the perceptive apparatus. 
The possibility of an hereditary or an acquired specific taint 
should always be remembered in these cases, and if there is the 
slightest evidence of such a factor in causation the internal ad- 
ministration of iodide of potassium is advisable. It may be 
given either alone or in connection with the pilocarpine. 

Politzer has derived, apparently, beneficial results from the 
administration of iodide of potassium, in fairly large doses, in 
cases where beginning otosclerosis of the labyrinth was sus- 
pected, and in which there was no history of hereditary or 
acquired specific disease. His plan of treatment is to give these 

* Archives of Otology, vol. xvii, p. 95. 



396 CHRONIC CATARRHAL OTITIS MEDIA. 

patients a course of iodide of potassium for a period of several 
weeks during each year. While this plan of treatment is worthy 
of trial, the uncertainty in diagnosis renders the reports far from 
convincing. 

The question of the propriety of treating the middle-ear 
condition when serious labyrinthine involvement coexists is 
still unsettled. The results obtained, no doubt, differ in indi- 
vidual cases, but I am sure that the rule is not constant that 
measures directed to the middle ear invariably aggravate the 
labyrinthine lesion. Our only guide in the matter is to examine 
our cases frequently and observe the effect of treatment. If 
we find that inflation, passive motion, or other measures directed 
to the tympanic condition, produce giddiness or an increase in 
the tinnitus, they should certainly not be persisted in. Numer- 
ous instances will be met with in which exactly the reverse takes 
place, the labyrinthine complications improving as the tym- 
panic structures resume a more normal condition. From what 
has already been said under prognosis, the general condition 
of the patient must be kept constantly in mind, and care must 
be taken to tax either his mental or physical powers as little 
as possible. Attention to the cutaneous, digestive, respiratory, 
and circulatory organs is imperative if we expect any favorable 
results from local measures. It is not wise to send these cases 
from home in the hope of obtaining permanent benefit from a 
change of climate, as the results obtained by climatic treatment 
are at the best uncertain. 



CHAPTER XXII. 

CHRONIC PURULENT OTITIS MEDIA. 

Etiology. — This disease may follow either an acute ca- 
tarrhal or an acute purulent inflammation of the tympanic 
cavity. In the former instance it occurs as the result of an 
infection of the discharge through atmospheric impurities, 
while as a sequel of the latter condition it represents the fail- 
ure upon the part of Nature to restore the affected structures 
to a normal condition. The term is often applied to all 
cases of aural disease in which the discharge from the mid- 
dle ear has existed for more than two or three months, or 
even to cases in which the ear is discharging when the pa- 
tient presents for treatment. Exactly when an affection 
ceases to be acute and becomes chronic is hard to deter- 
mine. For convenience, however, we may assume that a 
discharge from the middle ear which has failed to yield to 
proper therapeutic measures at the end of three months con- 
stitutes a symptom of a chronic inflammatory process. 

A tubercular and occasionally a specific diathesis also may 
give rise to the affection, the special germs of these diseases 
finding lodgment in the tympanum and setting up the pecul- 
iar inflammatory process characteristic of each. When the 
disease is of tubercular nature its onset is so insidious that 
the patient may not be able to state the exact period of its 
inception, the first knowledge which he has of an aural affec- 
tion being the appearance of a discharge in the meatus, while 
examination reveals a condition which could only result from 
a chronic inflammatory process. 

Pathology. — When we find a purulent discharge from the 
tympanum which has persisted for a long period we are 
forced to conclude that a certain amount of tissue necrosis 
has taken place. This is true whether the disease was at first 
of a catarrhal nature or was purulent from the beginning. 
The infection of a perfectly innocuous discharge from the 
tympanum must result in tissue necrosis unless the source of 

(397) 



398 



CHRONIC PURULENT OTITIS MEDIA. 



infection is removed at a very early period. Those parts of the 
tympanic cavity which are richly supplied with connective- 
tissue elements form an excellent nidus for the development 
of these germs, and when they are once infected it is prac- 
tically impossible for us to prevent considerable destruction 
of tissue. In the early stages the connective tissue alone may 
be involved, but very soon the osseous structures participate in 
the process, owing to an interference with their proper blood 
supply. Those parts are attacked first which are the least 
vascular and whose nutrient vessels are so situated as to be 
easily interfered with by any increase in pressure in the tym- 
panic cavity. The blood supply of the incus, it will be re- 
membered, is very limited, and is derived from the petrosal 
branch of the stylo-mastoid. From its situation its calibre is 
easily obliterated by any swelling in the upper portion of the 
tympanum. Hence when the ossicular chain is the seat of 
necrosis the incus usually suffers first, caries or necrosis of 
this ossicle being present in eighty-five per cent of all cases in 
which the ossicles are involved. The process may spread to 
the walls of the tympanum, usually to that portion of the ex- 
ternal wall which is formed by the auditory plate of the tem- 
poral. The internal wall of the middle ear is seldom affected, 
although it may be involved when the condition is tubercu- 
lar, or in cases following one of acute infectious diseases, such 
as scarlet fever or diphtheria. Since any profuse discharge 
from the meatus which has existed for several months must 
come from the middle ear, it goes without saying that the 
membrana tympani is perforated in all cases. The amount of 
local destruction and the particular region where the loss of 
substance occurs varies greatly. Complete destruction of the 
drum membrane is rarely seen, although the entire membrana 
vibrans may be wanting with the exception of the so-called 
cartilaginous ring, which marks the line of insertion into the 
annulus tympanicus. When only a small portion of the drum 
membrane is destroyed the perforation most frequently oc- 
curs in the posterior quadrant at the level of the umbo or 
slightly below it. When the osseous structures are involved 
and the disease has been of long duration we not infrequently 
find the perforation located in the upper and posterior quad- 
rant just below the incudo-stapedial articulation. The mem- 
brana tympani in these cases is often adherent to the internal 
wall of the middle ear ; its upper margin, however, is free, 



PATHOLOGY. 399 

and a probe passed beneath this may be directed upward into 
the tympanic vault, following the long process of the incus. 
The reason why this perforation is so characteristic of caries 
within the tympanum depends upon the fact that the avenue 
of exit for any fluid which has collected lies along the long 
process of the incus. In fact, this may be the only course 
which the secretion can follow, as no other portion of the 
ossicular chain passes from the upper part of this cavity into 
the atrium. Anteriorly the atrium is shut off from the tym- 
panic vault by the anterior and external ligaments and by the 
body and neck of the malleus. In addition to these structures, 
normally present, certain reduplications of mucous membrane 
are often found, and these may be so numerous and so dis- 
posed as to render it impossible for even air to pass from the 
vault of the tympanum into the cavity beneath. Perforation 
in this location is so commonly associated with caries of the 
incus that I have come to regard it as almost pathognomonic 
of the condition. More rarely we find the perforation located 
in the membrana flaccida, either just above the short process 
or above the posterior, or, more rarely, above the anterior 
ligament. A perforation above the short process always 
means intratympanic caries, and usually indicates that the 
malleus is affected, although this rule is not invariable. The 
extent to which the walls of the tympanum participate in the 
destructive process varies according to the care which has 
been exercised in keeping the ear properly cleansed, and the 
degree of infection which primarily produced the disease. 
Constitutional diatheses exert a marked influence upon the 
extent of involvment of the osseous walls; this is particularly 
true of the tubercular and specific diatheses, the bony parts 
breaking down rapidly when once local infection has taken 
place. 

Secondary involvement of the labyrinth is seldom met 
with in chronic suppuration. When present, the mischief has 
usually been done in the acute stage of the disease, and al- 
though both the oval and the round window may have re- 
mained bathed in pus for years, extension to the labyrinth 
seldom follows. This should not be taken to mean that the 
lower turn of the cochlea is functionally perfect in these 
chrpnic cases. It is more reasonable to explain the slight 
changes found here upon the ground that thev are produced 
by the alteration in pressure at the oval window due to ad he- 



4 oo CHRONIC PURULENT OTITIS MEDIA. 

sions about the stapes than to attribute the condition to an 
infection of the labyrinth. 

In addition to this mild form of labyrinthine involvement, 
causing merely impairment of hearing for the upper notes of 
the musical scale, it must always be borne in mind in every 
case either of acute or chronic suppuration of the middle ear, 
that there is a possibility of the extension of the inflammatory 
process directly to the labyrinth, either through the oval or 
round windows, or, in the case of chronic suppuration, of ero- 
sion of the external wall of the horizontal semicircular canal 
and propagation of the inflammation to the intralabyrinthine 
structures through this channel. In many cases, a suppurative 
inflammation of the labyrinth shows but little tendency to ex- 
tend and become general. In some cases, however, the entire 
labyrinth is destroyed by the suppurative process. When this 
occurs there is always great danger of the inflammatory process 
extending from the labyrinth to the cranial cavity and causing 
an involvement either of the dura or of the brain substance 
itself. The inflammatory process may extend either along the 
aquaeductus vestibuli and aquaeductus cochleae, or may simply 
follow the sheath of the auditory nerve inward through the in- 
ternal auditory meatus, the site of intracranial infection being 
frequently found in this latter region. 

Knapp * has reported a case in which extension to the intra- 
cranial contents occurred in this manner, giving rise to a puru- 
lent meningitis and to a small abscess in the. left cerebellar lobe 
in the region of the flocculus. The occurrence of cerebellar 
abscess in this case is interesting. Okada f has demonstrated 
that a large number of cerebellar abscesses follow labyrinthine 
suppuration. According to the statistics of this author, sup- 
puration of the labyrinth is a more potent cause of cerebellar 
abscess than is sinus thrombosis. 

Secondary involvement of the mastoid process constitutes 
the most grave complication from which these patients suffer. 
When drainage through the external canal is free the mastoid 
is seldom involved. If, however, the outflow through the canal 
is obstructed, the pus finds its way into the pneumatic spaces 
of the mastoid, an osteitis is set up, and more or less extensive 
bony destruction takes place. A change of considerable im- 

* Archives of Otology, vol. xxxi, p. 99. 

f Diagnose und Chirurgie des Otogenen Kleinhirnabscess, Haug's Klinische 
Vortrage, Jena, 1900. 



PATHOLOGY— CHOLESTEATOMA. 401 

portance, and one which is always present to a greater or less 
degree, is a chronic inflammation involving the mastoid. This 
is essentially a chronic proliferative osteitis, through which the 
pneumatic spaces are obliterated, and the entire mastoid process 
becomes converted into dense eburnated bone. This change 
may be so complete that all the air spaces are obliterated, and 
the antrum itself may be reduced in size. Only in those cases 
which have persisted for a long period of years and in which 
the process has been active is no trace of the antrum found. 

The obliteration of the pneumatic structure of the mastoid 
is of considerable importance from a clinical standpoint. In 
a pneumatic mastoid an acute exacerbation of the chronic in- 
flammatory process within the middle ear may perhaps result 
in an infection of the mastoid cells and the development of 
an acute mastoiditis, with all the signs characteristic of this 
condition. If, however, the mastoid is sclerotic, and the pneu- 
matic spaces have disappeared and the bone has become scle- 
rosed, an acute inflammation of the tympanum is apt to extend 
rapidly to the cranial cavity either through the tympanic roof 
to the middle cranial fossa or through the posterior wall of 
the mastoid to the lateral sinus or cerebellum. 

The development of a cholesteatoma following chronic sup- 
purative otitis depends upon the inflammatory process assum- 
ing a particular type, as the result of which the superficial epi- 
thelium covering the mucous membrane is formed rapidly and 
as rapidly desquamated, while the fluid products of inflamma- 
tion are slight or practically absent. As the result of the casting 
off of these epithelial cells there are formed, first in the vault 
of the tympanum, and later in the mastoid itself, irregular 
masses of epithelium, in which the cells are firmly packed to- 
gether. This process depends upon the transformation of the 
superficial epithelium lining the tympanum into epidermal 
cells. The change is probably due to the extension of the 
cutaneous lining of the canal into the middle ear through an 
opening in the membrana tympani. Such a condition follows 
perforation in Shrapnell's membrane more commonly than a 
solution of continuity in the membrana vibrans. In some in- 
stances these cutaneous cells become completely covered by the 
mucous membrane and by their proliferation form true cysts 
containing a mass of desquamated epithelium. 

The cases of cholesteatoma met with in which there is 
no evidence of a previous perforation of the drum mem- 
brane are probably the result of an inflammatory process 



402 



CHRONIC PURULENT OTITIS MEDIA. 



in infancy, at which time the drum membrane was perfor- 
ated. 

The acute symptoms which may be caused by the pres- 
ence of a cholesteatoma and the treatment of the condition 
will be considered later. As these masses increase in size 
slowly but constantly, they dilate the cavity in which they 
lie, displacing the surrounding walls. The mechanical irri- 
tation, due to the presence of the mass, causes a condensa- 
tion of the osseous tissue, or mastoid sclerosis. Another 
condition which may result from the development of these 
epithelial masses is absorption of the bony wall separating 
the meatus from the mastoid cells, the mastoid cells and ex- 
ternal canal being converted into one large cavity. If the 
bony walls are absorbed in the opposite direction, perforation 
into the cranial cavity may take place. Products of inflam- 
mation may enter the cranial cavity by transmission through 
the perforating veins or by local necrosis over any given area. 
According to the location and the exact nature of the local 
lesion, such an invasion of the cranial cavity may result in an 
epidural abscess, a diffuse meningitis, a brain abscess, or a 
sinus thrombosis. 

Symptomatology. — The one prominent symptom is, natu- 
rally, discharge from the ear, and although extensive destruc- 
tion may have taken place, this may be the only symptom 
of which the patient complains. The amount of discharge 
varies, in some cases being so profuse as to fill the meatus in 
spite of frequent cleansing ; at other times being discoverable 
only upon inspection of the ear by reflected light, the secre- 
tion drying upon the walls of the meatus and never appear- 
ing at the orifice of the canal. The degree of impairment of 
hearing is never indicative of the extent of the local process. 
It is not uncommon to find the entire membrana vibrans 
wanting, the incus completely destroyed, and the malleus 
carious, and yet the power of audition not noticeably im- 
paired. In other cases, where the lesions are less extensive, 
a high degree of deafness is present. Subjective noises are 
much less frequently met with in chronic suppuration than in 
the nonsuppurative form of inflammation. Attacks of vertigo 
may be complained of, dependent upon no assignable cause, 
or they may occur only when the ear is syringed. The dis- 
turbance of equilibrium may be but slight or so pronounced 
as to cause the patient to fall. When this symptom appears 



SYMPTOMATOLOGY. 403 

only upon syringing the ear, the drum membrane will usually 
exhibit a large perforation exposing the head of the stapes to 
the direct impact of the current. 

Chronic suppuration need not necessarily cause constant 
discharge from the ear. The patient may be free from the 
symptom for weeks or even years. This intermittency de- 
pends upon the precise nature of the local changes within the 
middle ear and also upon certain associated conditions of the 
upper air tract. In children where the membrana tympani 
has been extensively destroyed as the result of one of the 
exanthemata, we frequently have the history of a discharge 
from the ear only when the patient has a cold in the head. 
In such a case, usually, the internal wall of the middle ear is 
exposed over a very large area, and the mucous membrane 
covering it participates in any vascular changes which may 
take place in the associated organs. Hence an acute rhinitis 
or an acute naso-pharyngitis, especially if the pharyngeal ton- 
sil is hypertrophied, causes a similar hyperaemic condition of 
the mucous membrane of the middle ear. Add to this the 
exposure of the membrane by the loss of the membrana tym- 
pani, and it is easy to understand why the discharge recurs at 
such a time. The attack is really one of tubo tympanitis, but 
as the tympanum is freely open, the serous transudation ap- 
pears in the canal. In other instances inquiry will fail to 
elicit any history of discharge, but the patient may state 
that at intervals small yellowish-brown crusts collect in the 
meatus and constitute a source of annoyance. Careful ex- 
amination shows that these so-called crusts are masses of in- 
spissated pus which collect in the deeper portions of the canal 
and constitute a source of discomfort only when they appear 
at the orifice of the meatus. 

Certain symptoms referable to the external canal may also 
be present. The development of a fungus upon the walls of 
the meatus is not uncommon, as the parts are continually 
bathed in secretion. The symptoms may be so slight as to 
escape notice, or there may be an intense burning or stinging 
sensation in the ear, together with pruritus. Where proper 
attention is not paid to cleanliness, a circumscribed external 
otitis may result, producing the symptoms characteristic of 
this affection. Diffuse inflammation of the external meatus is 
rather uncommon unless the mastoid process is involved. 

The development of facial paralysis was formerly supposed 



404 



CHRONIC PURULENT OTITIS MEDIA. 



to be indicative of involvement of the mastoid. This is by 
no means true. The facial nerve in its passage through the 
tympanic cavity is ordinarily completely inclosed in a bony 
canal, and pressure symptoms are impossible unless this bony 
wall is wanting at some portion, either as an anomalous ana- 
tomical condition or as a result of necrosis. In either of these 
conditions the trunk of the nerve may be pressed upon and 
facial paralysis of the corresponding side result. Where the 
canal is imperfect the nerve itself may become inflamed and 
the integrity of the facial muscles be impaired without any 
inflammatory changes taking place in the bony wall. When 
cholesteatoma develops, the pressure upon the nerve trunk 
may produce this symptom when the bony wall has been 
incomplete originally or has been partially absorbed by 
pressure. 

The occurrence of granulation tissue suggests the pres- 
ence of necrotic bone, provided the ear has been kept thor- 
oughly cleansed, and its recurrence after removal, with sub- 
sequent thorough cleansing, is pathognomonic of diseased 
bone. Where the parts have not been thoroughly freed from 
the discharge the action of the heat of the body, together 
with the moisture, induces exuberant granulations to spring 
up about the edges of the perforation in the drum membrane, 
and may often excite a similar process from the internal tym- 
panic wall or from the various reduplications of mucous mem- 
brane within the middle ear, although the osseous structures 
may not be affected. These granulations, when they are due 
to hypernutrition of the soft tissues, yield very rapidly to 
chemical caustics if the parts are kept thoroughly cleansed, 
and a careful observation of their behavior under treatment 
enables us to recognize the involvement of the bony parts 
with absolute certainty. Where the secretion is very scanty, 
amounting to but a fraction of a minim daily, it may not 
escape from the meatus at all, but adhere to the walls of the 
canal and form a crust upon the posterior or superior wall of 
the meatus. Close to the membrana tympani it spreads down- 
ward and conceals it more or less completely. The presence 
of such a scale should always lead us to suspect a suppurative 
process within the tympanum, although the patient may deny 
positively that the ear has ever been the seat of a purulent dis- 
charge. In these cases there has usually been caries of the 
ossicular chain. Most frequently the incus has been the seat 



DIAGNOSIS— PHYSICAL EXAMINATION. 



405 



of the destructive process which may have occurred in early 
childhood, although it may not be discovered until adult life. 
The perforation is frequently small and situated high up in 
the membrana tympani in its flaccid portion. It is in these 
cases that we may have serious mastoid complications if the 
condition is allowed to go on unchecked ; in fact, the mas- 
toid inflammation may be the first symptom which causes 
the patient to direct his attention to the ear. More rarely 
the case is still more serious and intracranial infection takes 
place and progresses so insidiously that the patient is beyond 
all hope before the trouble is discovered. 

The symptoms which characterize labyrinthine involve- 
ment are sudden dizziness, nausea, and profound deafness. A 
moderate involvement of the labyrinthine structures is com- 
mon in cases where the disease has persisted for a long pe- 
riod. Notwithstanding this fact, the hearing may be but lit- 
tle impaired, the labyrinthine affection being confined to that 
part of the organ which is concerned in the appreciation in 
the highest notes of the scale — tones which are but little used 
in carrying on the ordinary vocations of life. 

Diagnosis. — A. Physical Examination. — It is impossible to 
describe the manifold appearances which may be observed 
in chronic purulent otitis. For convenience we may divide 
them into six groups : 

1. Destruction of the membrana tympani over a large area, 
with thickening of the mucous membrane over the internal 






Fig. 106. — Chronic 
purulent otitis me- 
dia. Extensive de- 
struction of the 
membrana vibrans. 



Fig. 107. — Chronic puru- 
lent otitis media. Ex- 
uberant granulation tis- 
sue developing within 
the tympanum. 



Fig. 108. — Chronic puru- 
lent otitis media. Mem- 
brana tympani adherent 
along inferior margin of 
perforation. 



tympanic wall and hypersecretion from the exposed surface 
(Fig. 106). 

2. Extensive destruction of the membrana vibrans, with the 
development of granulation tissue over the internal wall of the 
middle ear (Fig. 107). 

3. But slight destruction of the membrana vibrans, usually 



406 



CHRONIC PURULENT OTITIS MEDIA. 



in the posterior quadrant ; adhesions between the margin of 
the perforation and the internal tympanic wall, except at the 
upper border, where a sinus leads directly into the vault of 
the tympanum. In these cases granulation tissue may be 
present, protruding from the orifice of the sinus, or the 
channel may be perfectly free. This appearance is indicative 
of caries within the middle ear (Fig. 108). 

4. Membrana vibrans intact ; perforation through the mem- 
brana flaccida, above the short process of the malleus. Here 
granulation tissue may or may not be present. The appear- 
ance is always indicative of diseased bone (Fig. 109). 

5. Entire membrane swept away, except the cartilaginous 
ring and a small portion of Shrapnell's membrane which en- 



^ 



• 



<§ 



Fig. 109. — Perfora- 
tion above the 
short process of 
the malleus. 



Fig. 1 10. — Chronic 
purulent otitis me- 
dia. Ossicles dis- 
placed. 



Fig. hi. — Chronic puru- 
lent otitis media. Small 
perforation behind the 
umbo. 



velops the ossicula or their remnants, partial destruction of 
the chain, as a rule, having taken place. In these cases there 
is usually a sinus beneath the anterior or posterior ligament, 
sometimes in both situations (Fig. 1 10). 

6. A small perforation through the membrana vibrans, the 
drum membrane otherwise intact. This appearance is met 
with in childhood, and is indicative of infection of a simple 
catarrhal inflammation of the tympanic cavity, due usually to 
neglect (Fig. 1 1 1). 

In inspecting any case, particular attention should be paid 
to an investigation of the entire periphery of the membrana 
tympani. Not only the membrana vibrans, but especially that 
part lying about the short process, should be carefully exam- 
ined. This latter step should be taken, although a perforation 
may be present in the lower portion of the drum membrane, 
which seems to explain sufficiently the presence of the dis- 
charge. A coexistent loss of substance in Shrapnell's mem- 
brane may be found which will modify decidedly the prog- 
nosis in the case. 



DIAGNOSIS— PHYSICAL EXAMINATION. 407 

The free use of the probe is not difficult in these cases, 
since the middle ear is scarcely sensitive. We should deter- 
mine whether the discharge really proceeds from an exposed 
surface or simply flows over this, originating in the upper part 
of the tympanic cavity. When this is the case, it will always 
be possible to insert a delicate probe under the posterior or 
anterior fold and carry it upward into the vault. The sim- 
plest means of doing this is to wind a pledget of cotton firmly 
upon a small cotton-holder, the cotton extending for some dis- 
tance beyond the end of the instrument. If wound firmly, 
this cotton tip possesses considerable power of resistance, 
and causes less pain upon impact than does a metallic in- 
strument. The cotton should be bent at a right angle, the 
angular portion being about one eighth of an inch in length. 
It is sufficiently firm to permit its introduction beneath the 
anterior or posterior fold of the membrana or into the small 
perforation in its lower portion. By manipulation it should 
be carried successively to the different parts of the middle 
ear, when, if exposed bone is encountered, the operator will 
recognize the fact by the cotton catching upon the rough 
surface. When this is not felt, it is well, upon removing the 
instrument, to examine the cotton carefully by means of a 
magnifying glass. Contact with exposed bone will pull out 
some of the strands, and this sign is as positive an evidence 
of caries as that afforded by the use of the probe in any other 
portion of the body. 

Granulation tissue may develop to such an extent as to 
completely fill the meatus, in which case its recognition is a 
matter of no difficulty. In cases where it comes through a 
perforation in the membrana flaccida, it may be so closely 
applied to the periphery of the perforation as to render the 
line of demarcation almost indistinguishable. Here the mis- 
take may be made of confounding the appearance with a 
bulging of the upper portion of the drum membrane, but 
careful manipulation with the probe will reveal the true na- 
ture of the condition. The granulation tissue pits easilv on 
pressure, and the slight amount of mobility which it possesses 
points clearly to a pedunculated attachment. 

The mucous membrane covering the internal tympanic 
wall may resemble so closely the appearance of a bulged and 
reddened drum membrane as to mislead us, unless we bear in 
mind that where the membrana tympani is present we are 



4 o8 CHRONIC PURULENT OTITIS MEDIA. 

able to follow any one wall of the canal continuously across 
the fundus until it merges into the opposite wall, the outline 
being unbroken. If we are dealing with a case in which the 
internal wall of the middle ear is exposed, we shall find a 
solution of continuity at the very periphery, between the 
margin of the canal, which stops here abruptly, and the red- 
dened w r all of the middle ear, which lies at a lower level. 
The recollection of this simple fact will render a mistake in 
diagnosis rare. 

The recognition of the ossicula is frequently a matter of 
no small difficulty. The short process of the malleus usually 
preserves its normal position more nearly than any of the 
other landmarks, and should be first sought. When this is 
recognized, if the shaft is present, we can usually make it out. 
If it does not lie in its normal position, or if it is found to be 
slightly displaced backward and inward, the head of the 
patient should be tilted far over toward the opposite side and 
the region between the short process and the internal tym- 
panic wall carefully inspected. Necrosis of the tip of the 
malleus is not uncommon, and then the manubrium is usually 
slender, and drawn upward and inward by fibrous bands and 
completely hidden from view by the prominent short process 
and the hypertrophied posterior and anterior folds. 

It is of special importance to inspect the upper and pos- 
terior quadrant of the field for an explanation of the degree 
of functional impairment. The stapes may frequently be seen 
in this region lying close to the margin of the tympanic ring, 
and partially concealed by it. If the head of the patient is 
inclined well to the opposite side, and at the same time tilted 
a little backward, we are able to look beneath the obstruct- 
ing margin, and can usually recognize the head of the ossicle. 
Where extensive destruction has taken place the long process 
of the incus is often wanting ; if present, it may occupy its 
normal position, the incudo-stapedial articulation being clearly 
visible. When the lower portion alone is destroyed the rem- 
nant is usually displaced toward the malleus, lying between 
the manubrium mallei and the head of the stapes. 

Too much stress can not be laid upon the importance of 
first cleansing the ear most thoroughly by means of the cot- 
ton pledget and employing the probe, lightly touching each 
prominent point before attempting to interpret the condition 
of the parts. In an ear which has been properly cleansed an 



DIAGNOSIS— PHYSICAL EXAMINATION. 409 

exact diagnosis is not difficult if the normal anatomical posi- 
tion of the parts is borne in mind. Where any secretion is 
present an exact diagnosis is impossible, and a correct inter- 
pretation is the result more of good luck than of skill. In 
addition to the ossicula, certain landmarks may be recognized 
on the internal tympanic wall. In the anterior quadrant, 
either partly below or above the median plane, there is a 
hemispherical depression just at the margin of the ring, which 
marks the tympanic orifice of the Eustachian tube. In the 
posterior quadrant the promontory terminates close to the 
tympanic ring. This break in the outline marks the niche of 
the round window lying below the head of the stapes, and in 
a plane almost at right angles to the plane of the oval win- 
dow. Occasionally the niche of the fenestra rotunda is ex- 
ceedingly well marked, and when associated with a contrac- 
tion of the meatus at its inner end the promontory may be 
mistaken for an exostosis. 

Inflation by means of the catheter gives auscultatory 
sounds, which vary according as the middle ear is shut off 
from the Eustachian tube by adhesions, or where the tym- 
panic orifice is patent. When the inner extremity of the 
tube has been occluded by an hypertrophic process, no sound 
of air entering the tympanum is perceived, each compression 
of the bulb being heard as a faint, distinct, percussion sound. 
It is distinguished from the sound heard when the tube is 
occluded at the isthmus from the more immediate proximity 
to the ear of the observer, and also by the absence of mucous 
pharyngeal rhonchi, which usually accompany this latter con- 
dition. With a patent tube the sound varies from a full blow- 
ing sound where the perforation is large to a sharp whistling 
note when the air passes through a small opening. Fre- 
quently perforations in the upper part of the drum membrane 
do not modify the normal auscultatory signs because the 
tympanic vault is entirely shut off from the atrium by adhe- 
sions, and inflation produces the characteristic impact sound 
as the air impinges upon the drum membrane. 

Involvement of the mastoid process is characterized by 
pain and tenderness over the mastoid region externallv, and 
usually by a diminution in the amount of discharge. Within 
the canal we find the parts tender along the superior and pos- 
terior walls close to the tympanic ring. Very soon after the 

mastoid has been attacked the soft tissues in this reel 

28 



410 CHRONIC PURULENT OTITIS MEDIA. 

into the lumen of the meatus, narrowing the fundus, and in 
severe cases may lie in contact with the opposite wall. This 
prolapse of the supero-posterior wall of the bony canal is. 
pathognomonic of an inflammatory process within the mas- 
toid, and we need no other indication before resorting to im- 
mediate operative measures. The temperature is in nowise 
indicative of extension in this direction ; quite frequently the 
temperature remains normal, although the pneumatic spaces 
in communication with the tympanic cavity have become in- 
volved. 

B. Functional Examination. — The hearing for sharp sounds 
is reduced, and conversational voice and whispered speech 
may be heard as well or better than either the watch or acou- 
meter. The lower tone limit is elevated ; the upper tone 
limit is frequently normal, especially where the parts are 
moist, and where the process has not existed for many years. 
In some cases we find that high notes are better perceived 
than under normal conditions. Where the ear has been the 
seat of a purulent inflammation for a long period of years, 
the upper tone limit is often considerably lowered. This 
indicates labyrinthine involvement, which is usually not pro- 
gressive. Bone conduction is increased in most cases. Where 
one side alone is affected, the tuning fork on the vertex is 
heard better by the affected ear; the normal ratio between 
bone and air conduction is reversed for the lower notes of the 
scale, frequently for all notes below the c" — 512 V. D. The 
galvanic irritability is usually increased while the middle-ear 
process is active ; when this is quiescent such a reaction to 
the galvanic current would be indicative of labyrinthine 
inflammation or congestion. 

Prognosis. — We consider under prognosis, first, the degree 
of functional impairment which the patient will suffer ; sec- 
ond, the continuance or cessation of the discharge; third, the 
danger to life. 

In considering the probable degree of functional impair- 
ment, we must remember in general that a suppurative inflam- 
mation endangers the hearing much less than does a nonsup- 
purative process. The amount of destruction that has resulted 
furnishes us few data upon which to base an opinion. The 
condition of the parts in the upper and posterior quadrant, 
however, may aid us in estimating the probable degree of im- 
pairment which will result; if the stapes is exposed and is 



PROGNOSIS. 4 II 

movable upon manipulation and the niche of the round win- 
dow is unobstructed, deterioration of the hearing- should not 
take place beyond that originally present when the patient 
first comes under observation ; on the contrary we should 
expect it to improve considerably from the reduction of the 
inflammatory process and from surgical measures directed to- 
ward adhesions which may be present. When the stapes can 
not be seen but adhesions exist which, from their location, 
might fix it firmly, the chances of improvement are still good. 
With a normally movable stapes and where the round window 
is not occluded, it is not probable that any measure directed 
toward the middle ear will greatly increase the power of au- 
dition. In interpreting these appearances we naturally cor- 
relate the results of the functional and physical examinations. 
With labyrinthine involvement we may hope for improvement 
from internal medication, although a guarded opinion should 
be given as to the degree which will be attained. 

Concerning the cessation of discharge, the chief factor is 
the presence or absence of diseased bone and the extent to 
which the osseous tissues have been invaded. If we find that 
the bony ring has been involved and the disease is of long 
duration, it is quite probable that softening has occurred in 
regions inaccessible to instruments introduced through the 
meatus. If the ossicula alone are the seat of the necrotic pro- 
cess or if we believe that the walls of the middle ear are but 
slightly involved, our prognosis is then fairly good regarding 
the ultimate cessation of the otorrhcea. When no dead bone 
is present we should be able to promise absolutely that the 
discharge will cease under proper treatment. We can also 
promise that the danger of subsequent mastoid involvement 
will be removed. But in any given instance where the osseous 
structures have been invaded, to promise absolutely that the 
discharge will cease, is certainly unwise, 

Concerning the danger to life, we need only to remember 
that insurance companies constantly reject applicants suffer- 
ing from a chronic otorrhcea, to appreciate how grave a men- 
ace to life the condition is. Where the mastoid is not involved 
and an examination reveals no evidence of intracranial involve- 
ment at the time of the investigation, we can promise that bv 
properly conducted treatment the process will not endanger 
the life of the patient. With mastoid involvement there is al- 
ways a certain element of danger dependent upon the degree ; 



4I2 CHRONIC PURULENT OTITIS MEDIA. 

when intracranial changes have already taken place the prog- 
nosis is very grave. The variations in conditions which influ- 
ence our opinion when the mastoid is involved will be fully 
discussed in a chapter on this subject. Subjective noises, as 
a rule, are not distressing in the disease under discussion ; but 
when present, it is difficult to secure a complete subsidence of 
tinnitus unless it results from an acute exacerbation of the 
chronic disease. 

Treatment. — In the treatment of these cases we endeavor 
to accomplish two results : first, to stop the discharge ; sec- 
ond, to improve the hearing and relieve the subjective dis- 
turbances if any are present. 

In order to accomplish the first purpose it is necessary to 
see that the ear is kept thoroughly cleansed in order that the 
combined influence of heat and moisture may be removed. If 
the patient is to be treated at the hands of the surgeon every 
day and the discharge is only moderate in quantity, this may 
be removed in whatever way seems advisable, either with the 
cotton pledget or by irrigation with the syringe. If the treat- 
ment is to be conducted by the patient, irrigation affords the 
only safe means by which this object can be effected. The 
frequenc} 7 with Avhich irrigation should be repeated depends 
on the quantity of discharge, which must not be allowed to 
accumulate in the canal. In children, where the process is 
very active, or in cases that have been neglected for a long 
time, it is well to begin by having the ear syringed every two 
hours. The attendant or the patient himself must be in- 
structed carefully in the manner of performing this apparently 
simple operation. In the large majority of instances if this is 
not done the pus will not be thoroughly removed from the 
canal by the procedure ; consequently particular attention is 
directed to this point. In the adult patient the ear is to be 
drawn upward and backward by grasping the auricle between 
the index and middle fingers of the left hand, thus straight- 
ening the auditory meatus. The syringe should have a blunt 
nozzle, rendering it impossible for it to be carried in the 
meatus far enough to impinge upon the membrana tympani. 
After the irregularities in the canal have been overcome in 
the manner described, the syringe should be introduced into 
the meatus as far as possible and directed inward and slightly 
downward and forward toward the tip of the nose. In young 
children the curves of the canal are best obliterated by pull- 



TECHNIQUE OF SYRINGING. 413 

ing the auricle outward and downward, as shown in Fig. 87. 
If the syringe is pointed upward and inward the fluid will 
cleanse the deeper parts more thoroughly than if the direc- 
tions just given for the use of the syringe in adult patients 
are followed. The irrigating fluid is injected with a moderate 
amount of force, and the return current holding the pus in 
suspension is allowed to flow into any convenient receptacle 
which the attendant, or even the patient himself, holds under 
the ear close to the side of the face. The temperature of the 
fluid is a matter of considerable importance ; both hot and 
cold solutions are painful when introduced into the meatus, 
and the sensations of the patient should guide us in choosing 
the proper temperature. The amount to be used at each 
irrigation should not be less than half a pint, and it is fre- 
quently advisable to use more. 

Concerning the choice of a fluid for this purpose, we may 
use either a bichloride-of-mercury solution (1 to 5,000 or 1 to 
8,000) or water which has been boiled and allowed to cool to 
a lukewarm temperature, or a saturated solution of boric acid, 
or a two-per-cent solution of carbolic acid, or any other con- 
venient solution. In cases which have formerly been under 
treatment, and the patients know by experience the effect 
which fluids have upon the ear, the surgeon may be told 
occasionally that the result of the so-called " wet treatment " 
has been to increase the discharge. Many of these patients 
are able to wipe out the ears very successfully with a small 
pledget of cotton twisted about a bit of wood or upon a 
metallic cotton holder. We should never disregard these 
statements on the part of the patient without some good 
reason, and it is well not to insist upon the use of fluids if 
there is evidence that these have formerly increased the 
trouble. 

The removal of the discharge causes the swelling of the 
tissues within the middle ear to diminish, and with the disap- 
pearance of the congestion and oedema the discharge will 
diminish in quantity and the parts resume their normal ap- 
pearance. 

We should now carefully investigate as to the cause of the 
flow. If we find the mucous membrane within the middle 
ear exposed over a large area, as is the case when considera- 
ble of the membrana tympani has been destroyed, and the 
exposed mucous membrane is swollen, hypertrophied, t urges- 



414 



CHRONIC PURULENT OTITIS MEDIA. 



cent, and moist, the indication is to cause an absorption of 
the hypertrophied tissue and restore the local circulation to 
a normal condition. Certain conditions of the upper air pass- 
ages may tend to keep up a state of chronic congestion within 
the middle ear, and investigation of the nose and naso-pha- 
rynx should never be omitted. 

Where adenoid vegetations are found, it is well to begin 
our treatment by their removal. Enlarged faucial tonsils do 
not as frequently cause trouble, but if the organs are excess- 
ively hypertrophied, they should be removed. Hypertrophy 
of the turbinated bodies or other marked obstructive condi- 
tions in the nasal cavity also demand treatment, in order that 
there shall be no barrier to the free venous flow from the 
middle ear. 

Applications should also be made to the exposed lining 
membrane of the tympanum. For this purpose solutions of 
nitrate of silver may be employed, beginning with a two-per- 
cent solution, and rapidly increasing the strength, according 
to indications, up to two hundred and forty grains to the 
ounce, if necessary. The copper salts, if employed, should be 
used in less saturated solutions — ordinarily of a strength of not 
more than ten grains to the ounce. The practice of allowing 
these patients to instil astringent solutions into the ear is not 
advisable, particularly aqueous solutions of sulphate of zinc 
with a small amount of glycerin added, to retain the astrin- 
gent for a longer time in contact with the mucous membrane. 
A solution of this sort affords an excellent soil for the devel- 
opment of the various vegetable molds, and this occurrence 
often follows its continued use. If the patient is able to visit 
the surgeon only occasionally the preparation which is best 
adapted for his use at home is an alcoholic solution of boric 
acid in the proportion of twenty grains to the ounce. Where 
the internal wall of the tympanum is exposed over a large 
area, this solution produces particularly good results, the alco- 
hol acting as a local stimulant to the parts, while, in combi- 
nation with boric acid, it possesses sufficient antiseptic prop- 
erties to keep the parts free from the development of any of 
the low vegetable organisms. It also exerts a decided astrin- 
gent action, preventing the formation of granulation tissue. 

The use of powders which the patient is to blow into the 
ear can not be too strongly condemned. Under no condition 
should the patient be supplied with any remedy in this form. 



INSUFFLATION OF POWDERS. 



415 



Even in cases where the perforation is very large, it is pos- 
sible for a preparation of this character to dry into a firm 
crust after absorbing the discharge, and this crust may be- 
come so closely attached as to constitute a barrier to the free 
outflow of secretion, in case this becomes suddenly augmented 
in quantity at any time. Pus retention under these circum- 
stances does not differ from retention of purulent material 
from any other cause, and in a considerable number of cases 
death has resulted from the incautious use of powders. In 
the hands of the surgeon some of the astringent or stimu- 
lating powders are of great value. We sometimes find 
that after the discharge has been greatly reduced a small 
amount of moisture still persists, and the progress of the case 
stops at this point. The use of fluids in these cases seems to 
tend rather to keep up the discharge. The insufflation of a 
minute quantity of boric acid, oxide of zinc, iodoform, or a 
mixture of equal parts of alum and boric acid is frequently 
followed by a complete cessation of secretion, the ear remain- 
ing perfectly dry. The fact must be emphasized that but a 
minute quantity of any such preparation is to be used, just 
sufficient to cover the mucous membrane. In the case of 
boric acid a little may also be dusted upon the walls of the 
meatus, but the practice, sometimes recommended, of filling 
the canal w T ith the powder should never be adopted. In no 
case should powder be used even by the surgeon if an inter- 
val of more than forty-eight hours is to elapse before the next 
visit, and the patient should be directed immediately to 
syringe the ear thoroughly if at any time there is pain, giddi- 
ness or a considerable increase in the discharge. With these 
precautions I thoroughly approve of the use of powders, but 
under no other circumstances. 

In other cases we find that our efforts are unsuccessful, 
although most carefully conducted. This should always 
cause the suspicion of diseased bone in some portion of the 
tympanic cavity. Naturally this has already been sought 
in the first examination, but if treatment has been consci- 
entiously carried out in the manner described for a period 
of three to four weeks without reducing the quantity of 
the discharge considerably we may assume safely that dis- 
eased bone is the cause of the trouble. This applies to cases 
where no granulation tissue is present ; in many instances we 
find this additional symptom. Where, upon primary exami- 



416 CHRONIC PURULENT OTITIS MEDIA. 

nation, exuberant granulations are present to such a degree 
as to fill the fundus of the canal, or even if confined to a 
limited area, these should be dealt with before methods other 
than simple cleansing are instituted. If the granulations are 
of small size they may be destroyed in situ by the chemical 
or potential cautery. The chemical agents employed for this 
purpose are chromic acid or silver nitrate, either of which 
may be fused upon the end of a metal probe and lightly ap- 
plied to the granulation tissue after thoroughly drying the 
area to be touched. Any excess of the agent must be wiped 
away by means of a dry pledget of cotton to prevent it from 
spreading over the entire lining membrane of the middle ear. 




Fig. 112. — Removal of aural polyp with the snare. 

Where the tissue is soft and but little elevated above the 
general surface of the mucous membrane, a saturated solu- 
tion of persulphate of iron may be employed. Chromic acid 
is more suitable for the destruction of large granulations 
than any other chemical agent, since severe inflammatory re- 
action very rarely follows its use. The manipulation of the 
actual cautery is difficult, and is rarely more efficient than 
the means above mentioned. Where the granulations are 
of larger size they should be removed by means of the cold 
wire snare (Fig. 112), the loop being carried upward to the 
base and made to surround it, when by drawing the wire 
into the tube of the snare the growth is cut off close to its at- 



REMOVAL OF AURAL POLYPS. 



417 




FlG. 113. — Removal of aural polyp with 
the sharp curette. 



tachment. I much prefer this method to evulsing the growth 
after it has been surrounded by the loop. A practice which I 
often employ in these cases is removal of the tissue by means 
of the sharp curette (Fig. 1 13). 
Instruments of various sizes 
are necessary in order to per- 
form the operation effective- 
ly in this manner. The cu- 
rette is carried into the canal, 
passed below the growth, 
and then raised so that the 
ring of the instrument will 
encircle it ; by moving the 
curette delicately it can be 
carried upward along the 
pedicle to its point of attach- 
ment ; then, by pressing the 
instrument firmly against 
the wall of the canal, and at 
the same time drawing it outward, the mass is removed. 

This procedure is not painful if care is taken not to touch 
the walls of the meatus during the introduction of the instru- 
ment. The advantage of this method lies in the thorough 
extirpation of the mass, which is usually severed close to its 
base. After removal, a pledget of cotton is inserted into the 
canal and crowded rather firmly into the fundus to check 
whatever haemorrhage may occur. After a few moments it is 
removed and the parts thoroughly cleansed by the cotton 
pledget, after which the stump is cauterized. If, after a 
thorough removal in this manner and careful cleansing of the 
ear for a period of several days, the tissue reappears, dead 
bone is certainly present. No other condition but the pres- 
ence of a foreign body can cause this phenomenon, and meas- 
ures should at once be instituted to remove the offending; 
substance. 

It often happens, in an ear which has been the seat of puru- 
lent process since early childhood, that the discharge ceases 
and the ear remains practically dry, but occasionallv a small 
amount of offensive discharge appears at the meatus. It will 
frequently be found that this symptom is due to the presence 
of an aspergillus which has found lodgment and subsequently 
developed in the meatus or upon the internal tympanic wall. 



418 CHRONIC PURULENT OTITIS MEDIA. 

Owing to the presence of a slight amount of moisture it 
has developed in this situation, and afterward its presence 
increases the discharge, and thus facilitates its own growth. 
This fact is mentioned since its occurrence may mislead us as 
to the result obtained by previous treatment in any given case. 
In several cases in which the ossicles had been removed for 
caries, and the discharge had ceased completely, the patients 
returned after several months complaining that the discharge 
had reappeared. This was found to be due to the develop- 
ment of a fungus in the canal. Thorough cleansing and an 
application of a solution of the bichloride of mercury, in di- 
luted alcohol in the proportion of I to 2000, destroys such 
growths, and restores the parts to their previously quiescent 
condition. 

Where the discharge depends upon the lack of proper 
care in treating a previous acute catarrhal inflammation, we 
find that the perforation in the membrana tympani is of but 
small size, and that the purulent discharge is due to an infec- 
tion of the normal mucous secretion of the middle ear. After 
infection the fluid products are but imperfectly evacuated, 
owing to the narrowness of the opening. The first indication 
here is to secure free drainage by enlarging the opening with 
a blunt knife. If the fluid is viscid, it is frequentlv wise to 
make two diverging incisions, inclosing a V-shaped flap, to 
permit the complete evacuation of the contents of the cavity 
upon inflation of the middle ear. After thorough cleansing — 
first by inflation, and subsequently by irrigation of the tym- 
panic cavity by means of the middle-ear syringe (shown in 
Fig. 99), and thoroughly disinfecting the meatus — these cases 
may recover with no further treatment. If this does not 
occur, the lining of the tympanic cavity is to be stimulated 
by the injection of a mild astringent fluid, introduced by 
means of the tympanic syringe. The delicate delivery tube 
of the instrument is carried through the perforation and a 
sufficient quantity injected to fill the tympanum completely. 
We usually recognize the fact that a sufficient amount has 
been injected by the passage of the fluid through the Eusta- 
chian tube into the pharynx. We should never begin with a 
solution of nitrate of silver stronger than five grains to the 
ounce of water, subsequentlv increasing the strength as we 
find the parts tolerant to the drug. Only solutions sterilized 
bv heat should be used in this manner, and the instruments em- 



TREATMENT OF DISCHARGE FROM MIDDLE EAR. 4I q 

ployed must have been subjected to a similar process. Where 
the discharge still continues in spite of this treatment, and no 
condition is present in the nose or naso-pharynx which would 
tend to aggravate it, good results may often be obtained by ap- 
plying a paper dressing to the part after the middle ear has 
been thoroughly cleansed and the mucous membrane subjected 
to the action of appropriate drugs. This paper dressing was 
first used by Blake, and consists of a small bit of thin sized 
paper of appropriate shape, which is first moistened in a solu- 
tion of bichloride of mercury, i to 1,000, and conveyed into 
the middle ear by the forceps or upon the tip of the cotton 
holder. The surface of this disk of paper is applied to the 
drum membrane, and by manipulation so placed as to occlude 
the opening in it. When in position, its edges are firmly but 
delicately pressed upon, to secure close contact with the 
drum membrane at every point. The efficiency with which 
this has been done can be demonstrated by gently inflating 
the ear, when no perforation sound will be heard if the opera- 
tion has been satisfactorily performed. A little boric acid is 
now lightly dusted over the disk and the membrana tympani. 
This dressing will remain in place for a period varying from 
four days to two weeks, at the end of which time it will prob- 
ably have been carried toward the periphery of the mem- 
brane, exposing the margin of the perforation. Another 
dressing should now be applied in the same manner as before, 
overlapping the first disk, so that, as the exogenous growth 
of the membrane carries the first outward, the opening will 
be gradually occluded by the second dressing. The stimula- 
tion which the presence of this foreign body produces is fre- 
quently sufficient to effect a complete closure of the opening 
in the membrana tympani, while its protective action induces 
retrograde changes in the congested lining of the middle 
ear after securing free drainage by enlarging the opening. 
Where a sinus leading into the tympanic vault is present 
immediately beneath either the anterior or posterior fold, it is 
probable that the osseous structures have been involved bv 
the inflammatory process. If we do not detect the presence 
•of dead bone upon examination, the treatment detailed in 
the preceding pages may be followed for a few weeks ; but, 
in addition, the vault of the cavity should be irrigated bv 
means of the tympanic syringe, the delivery tube being- bent 
upward at its extremity, so as to admit oi insertion into the 



420 



CHRONIC PURULENT OTITIS MEDIA. 




Fig. 



14. — Irrigation of the tympanic 
vault. 



sinus and injection of the fluid into the upper spaces (Fig. 
1 14). Naturally such manipulation can only be carried on by 
the surgeon himself. The irrigation should be repeated at 
first daily, and subsequently less frequently, as the discharge 

diminishes in amount. In 
cases where bony necrosis 
has taken place the diseased 
bone may have been thrown 
off spontaneously, either dis- 
integrating and discharging 
in the form of pus, or it may 
have come away as a se- 
questrum at some former 
time. 

Here the persistence of 
discharge depends upon the 
retention of the secretion 
in the reduplications of the 
mucous membranes in the 
vault of the cavity. It is 
for this reason we are warranted in attempting at first to 
check the discharge by mild measures. Peroxide of hydro- 
gen, either dilute or ol full strength, has been highly recom- 
mended by some observers for the irrigation of this region ; 
aside from the fact that the antiseptic action of this drug is 
visible, I see no reason why it possesses any advantages over 
other solutions which are known to destroy pathogenic bac- 
teria. Certainly its entrance into the mastoid cells is unde- 
sirable because of the pressure exerted by the gas evolved 
during its action. 

Failing in any of these simpler measures, we may feel cer- 
tain that the discharge is due to the presence of diseased 
bone, and when we are confident of this fact the only rational 
procedure is to remove it. The extent to which the bony 
structures are involved influences the prognosis materially ; 
if confined to the ossicles the discharge will certainly cease 
upon ossiculectomy and thorough curetting of the tympanic 
walls. If the process is so extensive as to involve the osse- 
ous walls in regions inaccessible to instruments introduced 
through the meatus, the removal of the ossicles may still be 
indicated for the purpose of securing free drainage of the 
intratympanic spaces, although the discharge may not entire- 



OPERATIVE PROCEDURES FOR OTORRHCEA. 421 

ly cease. When there is sagging of the superior wall of the 
canal, a history of previous mastoid symptoms or mastoid ten- 
derness, and a purulent discharge so profuse that it must origi- 
nate in a cavity of greater size than the middle ear, the ideal 
procedure is an external operation, completely exposing the 
pneumatic spaces of the mastoid, together with the walls of the 
tympanum. Theoretically, such an operation should always 
result in a complete cure. Practically, the results obtained are 
frequently so satisfactory after the operation for removal of the 
ossicles and curetting the adjacent tympanic walls through the 
meatus that this operation is frequently chosen by the surgeon, 
and often with most satisfactory results. Unfortunately, even 
after a complete radical operation, some little discharge will re- 
main. In doubtful cases the surgeon is justified in recommend- 
ing the simpler operation first, giving the patient to understand 
that if this procedure is not followed by complete cure, and if 
disagreeable symptoms still continue, the more extensive opera- 
tion will be necessary. 

Operative procedures can not be too strongly urged in all 
cases where the presence of diseased bone is made out either 
by tactile examination or is quite as certainly indicated by 
the persistence of the discharge in spite of appropriate treat- 
ment. 

Regarding the efficacy of the operation of excision of the 
ossicles and curettement of the tympanum, Ludewig * reported 
forty-two cures in seventy-five cases operated upon. Grunert f 
cited thirteen cures in twenty-eight operations. The author $ 
reported nearly two years ago fifteen cures in twenty-nine cases 
operated upon, while in nine the discharge was greatly reduced 
in quantity. The author's later operations have given about 
the same results. In a total of ninety-two cases operated upon, 
fifty-three have been cured, twenty-five improved, and two un- 
improved. In the remaining twelve cases the result is un- 
known. Of the cases last mentioned two were seen but once 
after the operation; the others were improving when last seen. 

So far we have considered the effect of treatment upon the 
discharge alone. Concerning the function of the organ, it may 
be said that, in cases of extensive destruction of the membrana 

* Arch, fur Ohrenheilk., vol. xxx, p. 263. 
f Ibid., vol. xxxiii, p. 207. 

\ Supplement to Reference Handbook of Medical Sciences, New York, 1S93. 
p. 244. 



422 CHRONIC PURULENT OTITIS MEDIA. 

tympani and the formation of adhesions between the ossic- 
ula, the power of audition may diminish slightly, owing to 
the increased tension, after the parts become perfectly dry. 
This fact does not render the necessity or advisability of stop- 
ping the discharge less imperative, since any resulting impair- 
ment of function can be corrected by division of the adhesions 
at a subsequent period, while the continued secretion of pus 
is a constant menace to life. Following surgical procedures, 
the function of the organ is usually improved where the hear- 
ing is considerably impaired before the operation. Where 
the hearing is but slightly impaired we need not fear that it 
will be reduced by the operative measures proposed. Lude- 
wig * reports a slight impairment of the hearing as a result of 
the operation in six cases out of seventy-five operated upon. 
In my own cases but one instance of this kind has occurred in 
fifty operations. Impairment of the function more frequently 
follows the cessation of the discharge from treatment with 
astringents or caustics than from the method now under con- 
sideration. We assume here that the impairment in function 
is due principally to the intratympanic lesion and not to any 
labyrinthine involvement. Extensive involvement of the laby- 
rinth would contraindicate an operation for the improvement 
of hearing alone, but should scarcely stand in the way of the 
procedure for the relief of the discharge. The relief of sub- 
jective noises can very rarely be promised from any form 
of treatment, although where the mucous membrane is very 
much congested we should hope to abate their intensity as 
we reduce the turgescence. It is never safe to promise re- 
lief from this symptom by operative measures. On the other 
hand, these last-named procedures seldom or never produce 
subjective noises. 

The changes which take place in the tympanic mucous 
membrane after the removal of the ossicles and of the rem- 
nant of the membrana tympani vary considerably in differ- 
ent cases. The most favorable change is one in which the 
mucous membrane gradually undergoes dermoid transfor- 
mation. If this occurs, the membrane no longer secretes, 
and the patient is not liable to recurrent attacks of dis- 
charge from the ear whenever the upper air tract becomes 
acutely inflamed. In children this transformation takes 

* Arch, fur Ohrenheilk., vol. xxx, p. 263. 



TREATMENT OF OTORRHCEA AFTER OPERATION. 423 

place only after a long period, but in adults we may hope 
for it in from eight to ten months after the operation. Cer- 
tain steps at the time of the operation may hasten this trans- 
formation. Thus, if a small segment of the membrana tym- 
pani is allowed to remain at the lower part, and the mucous 
membrane over the promontory immediately opposite this 
segment is denuded by means of the curette, this small flap 
will apply itself to the denuded surface and rapidly become 
attached. The superficial epithelium spreads over the wall 
of the middle ear, transforming it into a nonsecreting sur- 
face. Where the mucous membrane remains intact, even al- 
though our procedure may have stopped the discharge per- 
manently, we should remember that any severe congestion or 
inflammation of the upper air tract, such as a severe cold in 
the head, may produce a temporary otorrhcea ; this will usu- 
ally subside spontaneously when the exciting cause has dis- 
appeared. In order that this may happen, the canal must be 
kept free from any infection while the discharge lasts. This 
end may be attained by cleansing the canal with the syringe 
twice daily. The solution to be employed should be of a 
mild antiseptic character. A solution of bichloride of mer- 
cury (1 to 8,000) answers the purpose admirably. After irri- 
gation the patient should instil a few drops of an alcoholic 
solution of boric acid (gr. xx to §j) or of bichloride of mer- 
cury (r to 3,000) into the ear. 

If the discharge is but slight and the patient is seen daily 
it may be sufficient to dry the parts thoroughly with cotton 
and then apply one of the alcoholic solutions above men- 
tioned to the walls of the meatus and middle ear with the 
cotton applicator. If these measures are carefully carried 
out the discharge will cease in' a few days. A condition 
which we may sometimes be called upon to combat by oper- 
ative interference is where this dermoid transformation takes 
place spontaneously in cases which have not been subjected 
to treatment. Where a small perforation is present in the 
upper portion of the drum membrane the epithelium of its 
outer surface occasionally grows into the tympanic cavity, 
where it proliferates, lining the entire vault with epidermis. 
Owing to the increased vascularity of the part, this new lin- 
ing membrane becomes the seat of a desquamative inflamma- 
tion, superficial cells being produced and thrown off more 
rapidly than under normal conditions. The cavity becomes 



424 



CHRONIC PURULENT OTITIS MEDIA. 



filled with desquamated epithelial cells, and exactly the same 
result follows as when a similar condition is present in the 
external meatus. The bony walls of the cavity are absorbed, 
and at the same time undergo consolidation as the result of 
chronic osteitis. An acute inflammation in an organ thus 
affected causes a sudden augmentation in the volume of 
this epithelial mass, and increases the pressure upon the sur- 
rounding walls. Sometimes the process is so insidious that 
the patient may not be cognizant of morbid changes in the 
ear until these symptoms, due to the sudden change, su- 
pervene, and the surgeon may first be consulted when oper- 
ative measures alone will relieve the case. The problem 
which we have to solve in such an event is whether we shall 
relieve the symptoms by an operation through the canal, 
or whether it is necessary to open the mastoid. Experience 
shows that the changes may be confined to the vault of the 
tympanum. In recent cases, and where no marked mastoid 
symptoms exist, such as external tenderness, pronounced and 
extensive sinking of the posterior wall of the canal, and spon- 
taneous pain over the mastoid, I am inclined to prefer clear- 
ing out the vault of the tympanum through the canal as a 
primary procedure. Frequently this is sufficient, and entire 
relief to the pressure symptoms follows, while at the same 
time the purulent condition is permanently arrested. When 
the process has invaded the mastoid, any operative procedure 
must not only remove the accumulation within the cells, but 
must also place these pneumatic spaces in communication 
with the meatus, in order that subsequent trouble may be 
avoided. From the nature of the pathological condition it 
may be practically impossible to extirpate every vestige of 
the lining membrane which has undergone dermoid trans- 
formation, and a recurrence may take place. It is our duty 
to establish a condition which will enable any subsequent 
accumulation to be removed without a severe operation. To 
effect this the mastoid is opened in the usual way, and the 
cell structure obliterated by means of the curette, after which 
the dividing wall between the artificial opening and the me- 
atus is taken away, throwing the mastoid cells and external 
canal into one cavity. The posterior wall of the fibrous canal 
is divided longitudinally, and the two flaps thus formed turned 
back into the bony cavitv and retained in position by a tam- 
pon of gauze. Any subsequent accumulation can now be 



THERAPEUTIC MEASURES IN OTORRHGEA. 425 

removed in the manner ordinarily employed in dealing with 
desquamative external otitis. 

This procedure is known as the Stacke-Schwartze opera- 
tion (for technique of operation, see page 546). Out of seventy 
cases operated on by this method, fifty-three were cured, eight 
were improved, seven are still under treatment, one is unim- 
proved, and in one case the result is unknown. 

We have limited ourselves to local measures in consider- 
ing the treatment. In patients of a lymphatic habit, particu- 
larly in children, much benefit will be gained by the internal 
administration of iodide of iron in full doses. Where evidences 
of malnutrition exist as the result of some hereditary diathesis 
the exhibition of cod-liver oil and of the hypophosphites will 
be found beneficial. In the adult attention should be given to 
regulating the habits of life so as to diminish the tendency to 
congestion in the upper air tract as much as possible. The 
use of alcohol, and in certain cases of tobacco, is particularly to 
be interdicted, although the influence of the latter is compara- 
tively slight. 



29 



CHAPTER XXIII. 

OTITIS MEDIA PURULENTA RESIDUA. 

By this term we designate that class of cases in which a 
former purulent inflammation has resulted in a permanent 
destruction of certain of the tympanic structures. Either 
spontaneously or as the result of treatment, the discharge has 
ceased, and we are called upon to relieve symptoms due 
either to the adhesions which have developed within the 
tympanum or to certain changes which have resulted from 
the purulent inflammation. For convenience we divide these 
cases into two classes : 

i. Where the symptoms are acute or subacute. 

2. Where the symptoms are of a chronic character. 

i. Acute Cases. 

Etiology. — The underlying cause in these cases is evident 
from the title applied. As an exciting cause we may have 
any of those operative in the production of the various varie- 
ties of acute inflammation, but we usually find an acute in- 
flammation of the upper air tract, either a simple coryza, an 
acute naso-pharyngitis, or an influenza of the epidemic char- 
acter. Among other exciting causes we must bear in mind 
those which operate through the external meatus, such as the 
insertion of any device into the canal for cleansing the ear, 
blows upon the auricle, and the development within the 
tympanum of some of the vegetable molds. 

Pathology. — The changes which take place vary widely 
according to the condition in which the previous inflamma- 
tory process has left the parts. Cases in which the mem- 
brana tympani has been almost completely destroyed, expos- 
ing a large area of the inner wall of the middle ear, present 
generally a simple venous f^persemia of this membrane, re- 
sulting in oedema, and subsequently in serous transudation. 
The condition found here is similar to that described under 

uz6j 



PATHOLOGY AND SYMPTOMATOLOGY. 427 

acute catarrhal otitis media, or tubo-tympanic congestion oc- 
curring in an organ in which the membrana tympani is in- 
tact. In the cases under consideration the serous transuda- 
tion, which results from the inflammatory process, appears in 
the external auditory meatus as a discharge, for the reason 
simply that the opening in the drum membrane allows it to 
escape from the tympanic cavity. Where the membrana 
tympani is intact the same transudation collects within the 
middle ear. It is a matter of some importance to remember 
this, as such a discharge does not become purulent unless 
infected from without. If the external meatus is kept in a 
thoroughly aseptic condition, the disease is self-limited and 
the discharge ceases spontaneously at the end of a few days. 
On the other hand, if infection occur, a chronic purulent 
otitis may result. The remaining portion of the membrana 
tympani is affected, becoming hypersemic, desquamating if 
the process is pronounced, and increasing in thickness. 
Where the upper portion of the drum membrane remains, 
and the intratympanic folds has become much thickened 
by the development of new connective tissue, these lamellse 
increase in volume, and may completely fill the vault. If this 
portion of the. cavity is completely shut off from the atrium 
the subsequent transudation causes a bulging of the mem- 
brana flaccida, which may protrude into the canal so as to 
resemble closely a mass of granulation tissue. From the 
changes which have taken place it is usually so dense that the 
fluid inclosed can not escape by spontaneous rupture. The 
case then presents the characteristics of a primary acute pu- 
rulent inflammation of the middle ear, with the exception 
that the osseous walls become involved more quickly than 
when the affection is primary. Destruction either of some 
part of the ossicular chain or of the surrounding tympanic 
walls results, and with a subsidence of the acute symptoms a 
chronic purulent otitis remains. When cholesteatomatous 
changes have taken place the involvement either of the mas- 
toid cells or of the cranial cavity itself is exceedingly prone 
to occur. 

Symptomatology. — In the cases in which the membrana 
tympani is destroyed over a large area, the symptoms consist 
of a slight impairment of the hearing, occasionally with the 
development of subjective noises. The prominent feature, 
however, is the appearance of a discharge from the ear 



428 OTITIS MEDIA PURULEXTA RESIDUA. 

This class of cases occurs most frequently in children of from 
eight to twelve years of age, in whom the chronic purulent 
otitis has followed one of the exanthemata in early life. Pain 
is not a prominent symptom as a rule, and were it not for the 
appearance of the discharge the attack would probably pass 
unnoticed. Occasionally we may have developed in the ex- 
ternal canal an area of circumscribed inflammation due to 
local infection ; when this occurs there is intense pain. In 
the cases in which the upper part of the cavity is affected the 
pain is severe,, prostration well marked, the temperature is 
elevated from one to four degrees, and there may be no dis- 
charge, or, if present, it is usually scantv. The pain raav be 
localized in the ear or may spread to the entire temporal 
region. 

The occurrence of facial paralysis very early in the attack 
is not infrequent. The function of the organ may be but 
slightly impaired, owing to the location of the affected area. 

Diagnosis. — The result of functional examination depends 
so much upon the previous condition that it need not be 
considered, acute symptoms alone demanding attention. 

Physical Examination. — Upon inspection, where we find 
that the destruction of the drum membrane has been exten- 
sive, the exposed lining of the tympanum is red, velvetv in 
appearance, and coated either with a colorless watery dis- 
charge, or, at a later period this is opaque in character. 
The remnant of the drum membrane is thickened, tumescent, 
and cedematous. When examined before the process is far 
advanced, it may present a dead-white appearance, owing to 
a necrosis of the superficial layer of its epithelium. Removal 
of this epithelial covering reveals a turgidity of the underlying 
parts. Where the upper segment of the cavity is involved, 
the remnant of the drum membrane is intensely congested, 
thickened, and, together with the adjacent canal wall, bulges 
into the lumen of the passage, narrowing the fundus to so 
marked a degree as completely to fill the inner extremity of 
the canal in some cases and prevent an inspection of the re- 
gion of the atrium. This obstructing mass may be movable 
upon manipulation with the probe, and present many of the 
characteristics of granulation tissue. Impact with the probe 
shows that it is too firm and dense for granulation tissue. It 
does not bleed easily when touched, and, although movable, 
its attachment is broad. Careful inspection will usually en- 



DIAGNOSIS AND PROGNOSIS. 



429 



able us to make out that its surface is continuous with the 
supero-posterior canal wall, thus establishing its identity. The 
mass is exquisitely tender to pressure. Very little discharge 
is present, but the surface of the drum membrane and the ad- 
jacent walls of the canal are the seat of a desquamative pro- 
cess, and upon removing the epithelium, considerable serous 
transudation may take place, rendering exact diagnosis diffi- 
cult. Inflation with the catheter or air bag reveals no per- 
foration sound, the impact of the current being perceived as 
a dull, distant percussion sound, occasionally accompanied by 
bubbling rales. The conditions with which this may be con- 
founded are the presence of exuberant granulations, from 
which we have already given the means of differentiation, and 
a circumscribed external otitis. This latter condition, we 
remember, usually affects the fibro-cartilaginous meatus, and 
after the speculum has once passed the orifice of the canal, 
the lumen appears of normal size. It may occasionally be 
mistaken for a diffuse external otitis, but here the canal is 
uniformly narrowed, the deeper portion of the postero-supe- 
rior wall being affected no more prominently than its entire 
length. Tenderness over the mastoid region denotes an in- 
volvement of the pneumatic spaces, but a much better sign is 
the appearance already described in the canal. When, there- 
fore, the appearance is indicative of a circumscribed otitis of 
the deep canal, we are to remember that this condition is 
almost pathognomonic of mastoid involvement, and are to 
proceed to treat the mastoid inflammation without delay. 

Prognosis. — The cases in which discharge alone is the 
symptom almost invariably terminate favorably, often without 
treatment. If neglected, infection may take place, and a 
chronic purulent condition supervene. The occurrence of 
one attack probably renders the patient more prone to a simi- 
lar process in future. In the cases attended by pain the 
condition is practically one of cellulitis, and should never be 
considered lightly. If left to itself, it may resolve spontane- 
ously, or the fluid may escape into the atrium and then into 
the canal, or rupture may take place through the superior 
segment of the drum membrane. If spontaneous resolution 
does not take place, evacuation in either manner mentioned 
above seldom occurs before the bony parts are seriously in- 
volved, and a permanent discharge is a frequent outcome. 
If discharge does not take place, involvement ot the mastoid 



430 OTITIS MEDIA PURULENTA RESIDUA. 

cells or an extension to the intracranial contents, either by 
rupture or by infection through the venous channels, may 
occur. Concerning the effect upon audition, there is little 
danger that the function of the organ will be changed by such 
an intercurrent attack, the degree of impairment which was 
formerly present persisting but suffering no aggravation. 

Treatment. — For the relief of the discharge, attention to 
cleanliness is all that is necessary. Irrigation with a mild 
solution of any of the well-known antiseptics, repeated as 
frequently as may be necessary to keep the canal free of dis- 
charge, is usually the only treatment required. This measure, 
in addition to cleansing the parts, causes a certain amount of 
depletion, which hastens resolution. In order that no secre- 
tion may remain in the middle ear, it is well to inflate by 
means of the air bag or by the Valsalva method before irriga- 
tion. In the early stages remedies directed toward stopping 
the discharge are contraindicated. When the more acute 
symptoms have passed away, if the discharge continues, we 
may follow each irrigation by the instillation of a solution of 
boric acid in alcohol in the proportion of twenty grains to 
the ounce, or a i-to-3,000 solution of the bichloride of mercury 
dissolved in equal parts of alcohol, and water may be em- 
ployed in the same manner. Occasional applications of me- 
tallic astringents — such as solutions of nitrate of silver, from 
two to twelve per cent — will frequently hasten the return to 
the normal condition. Where the discharge is small in 
amount but fails to cease entirely, we may discontinue irri- 
gation altogether and rely upon insufflation of powders. Of 
these, nothing is better than boric acid, either alone or with 
the addition of iodoform, alum, iodol, etc. In making appli- 
cations of this character, but a small quantity of the powder 
should be used, to avoid mechanical obstruction to any fluid 
which may be transuded. 

If, in spite of intelligent treatment, the discharge contin- 
ues, we are warranted in the supposition that the osseous 
structures have become involved, and relief will follow only 
the removal of the diseased bone. To guard against recur- 
rent attacks, attention to the upper air passages is of the 
greatest importance. These recurrent cases usually occur in 
children under fifteen years of age, and in many instances we 
find that the vault of the pharynx contains an excessive 
amount of lymphatic tissue, while the faucial tonsils may 



TREATMENT. 43 1 

also be hypertrophied. These conditions call for operative 
treatment, or topical applications, as may seem best adapted 
to the particular case. Any obstructive lesion in the nasal 
passages must also be overcome by operative or other 
methods. 

Where the upper portion of the tympanic cavity is the 
seat of the process, the first indication is to relieve the pain, 
and at the same time to abort the local condition ; or, if too 
far advanced for this, to evacuate the products of inflamma- 
tion. To effect the first object, the patient should be put to 
bed and a full dose of opium or morphine administered, while 
at the same time local depletion should be employed. Un- 
doubtedly the best method of attaining this end is a free in- 
cision through the upper part of the membrana tympani 
behind the short process of the malleus. This incision should 
extend from the last-named point backward to the canal wall, 
and may be continued outward upon its surface for from a 
sixteenth to a quarter of an inch ; this I believe should be 
done whether any bulging is present or not. If fluid has al- 
ready been effused and there are evidences of obstruction to 
its free discharge, the procedure is imperatively demanded. 
If this stage has not been reached, the local depletion will 
probably check its progress. If it does not seem advisable 
to incise the parts, the application of natural leeches or of 
the artificial leech in front of the tragus, removing from one 
to two ounces of blood, according to the age and condition 
of the patient, is the procedure to be employed. The appli- 
cation of cold to the mastoid is proper if there is the least 
suggestion of swelling along the posterior wall of the canal ; 
irrigation of the parts with warm aseptic or antiseptic solu- 
tions should be begun at once, whether an incision has been 
made or not. If this has been done it will favor the haemor- 
rhage and render our efforts at aborting the attack more cer- 
tain, while if no surgical measures have been instituted the 
combined effect of heat and moisture may so reduce the 
tumefaction as to permit the discharge of the fluid products 
through the atrium, or may possibly lead to resolution with- 
out the supervention of discharge. The internal adminis- 
tration of analgesics is contraindicated after the first twenty. 
four or thirty-six hours, as it serves only to mask the symp- 
toms. If relief is not obtained at the end of this time, and 
surgical measures have been delayed, they must now be in- 



432 OTITIS MEDIA PURULENTA RESIDUA. 

sisted upon, and a free section of the tissues involved must 
be made. The use of the ice coil should not be persisted in 
for more than forty-eight hours : if. in spite of its use, the 
pain continues severe and the mastoid is tender upon pres- 
sure, or even if there is no tenderness, if the postero-superior 
wall is depressed, the process has almost certainly extended 
to the pneumatic spaces of this structure, and operation 
should not be delayed. Regarding the value of Wilde's in- 
cision in these cases, I can only say that I never employ the 
measure. If the symptoms do not seem prominent enough 
to warrant the opening of the mastoid, incision of the over- 
lying parts on its anterior surface, which forms the posterior 
and superior walls of the meatus, is the measure which will 
most probably give relief. It certainly possesses all the bene- 
fits of the external incision, both as regards the relief of ten- 
sion and depletion, and may very properly be employed as a 
last resort before opening the mastoid process. In this class 
of cases I think we can not too strongly insist upon an early 
mastoid operation if the symptoms do not disappear promptly. 
The advantages of this are not only the immediate relief to 
the present condition, but also the certainty with which a 
subsequent chronic purulent otitis media is prevented. Un- 
less checked by radical measures, the affection is almost cer- 
tain to be followed by a chronic otorrhcea. although the pres- 
ent attack may be recovered from. Where an operation is 
performed early we usually avoid this, and the period of con- 
valescence is much shortened. Another advantage is that 
recurrence is decidedly uncommon in cases operated upon, 
whereas those cases which recover without operation are 
specially prone to recurrence of the condition. Operations 
to obtain drainage through the meatus can not be advised : 
no doubt in some instances they are successful, but the en- 
gorgement of the parts is so great that the haemorrhage must 
be considerable, and in the narrow field of operation this pre- 
sents an almost insurmountable obstacle. 

2. Chronic Type. 

Under this term is comprised those cases whose symp- 
toms depend upon the changes which have taken place as the 
result of persistent inflammation. These either remain con- 
stant or increase very slowly, according as the connective 
tissue developed as a result of the pathological condition is 






CHRONIC TYPE : ITS PATHOLOGY. 



433 



in a perfectly quiescent condition, or is slowly undergoing 
secondary sclerotic changes. The condition is comprised 
under the general term " rigidity of the ossicular chain," and 
the affection is by some authors denominated as " otitis media 
sclerotica." Owing to the increase in fibrous tissue within 
the middle ear, the entire ossicular chain is carried inward 
toward the internal wall ; the foot plate of the stapes is 
crowded into the oval window, causing an increase in laby- 
rinthine pressure, while at the same time the outward move- 
ment of the membrana tympani secondaria is impeded 
through a process of a similar character in this region. We 
have, then, the labyrinthine fluid subjected to a permanent 
increase in pressure. No doubt the equilibrium is partially 
restored by the passage of the fluid through the channels 
communicating with the subdural lymph spaces. Where the 
increase of pressure is but moderate in amount this may so 
far compensate for the inward movement of the stapes as to 
render the condition of equilibrium practically perfect, in 
which case no symptoms arise. More frequently the in- 
creased tension persists, producing in the early stages the 
symptoms characteristic of acute labyrinthine pressure, while 
at a later period evidences of atrophy of the terminal fila- 
ments of the auditory nerve manifest themselves, the con- 
tinued pressure destroying these structures. 

Pathology. — Following the same general classification of 
gross pathological appearances already described in treating 
of chronic purulent otitis media, it is not difficult to under- 
stand how in each individual class the action of the conduct- 
ing chain in response to aerial vibrations is seriously inter- 
fered with. We may classify the interference with sound 
transmission in these cases as due to — 

i. Simple oedema of the mucous membrane. 

2. The presence of localized areas of hypertrophy due to 
chronic inflammation. 

3. Adhesions either between the various members of the 
ossicular chain or between the malleus and incus and the in- 
ternal tympanic wall. 

4. Cicatricial bands in the membrana tympani. The mem- 
brana tympani itself may, as the result of a chronic inflam- 
mation, press the entire ossicular chain inward. This is spe- 
cially true of cases in which a large portion of the membrane 
has been destroyed and the margin of the perforation coin- 



434 



OTITIS MEDIA PURULENTA RESIDUA. 



cides with the posterior fold. A dense band frequently de- 
velops here, which crowds either the stapes or incus inward, 
causing serious impairment of function. 

5 Adhesions limited to the region of the stapes. These 
adhesions develop either between the foot plate and the oval 
window, or between the crura and the walls of the pelvis 
ovalis, or from dense bands about the tendon of the stapedius 
muscle. 

This classification, it is understood, is merely general; any 
of the conditions may exist singly, or several may be pres- 
ent in the same case. In general it may be said that the im- 
pairment in hearing and tinnitus undergo but little change 
in those cases where the functional disturbance is due to a 
deposit of new connective tissue either in the remnant of the 
membrana tympani or between the various ossicula them- 
selves, or between the ossicles and the tympanic walls. 
Where the drum membrane is destroyed over a large area 
and the lining of the tympanic cavity is exposed, the power 
of audition frequently varies considerably at different times. 
Such changes usually depend upon congestion of the lining 
of the middle ear, or upon an accumulation of inspissated 
secretion in the deeper portions of the canal. In many of 

these cases, although there is 
apparently no discharge, the mu- 
cous membrane has not under- 
gone complete dermoid trans- 
formation, and consequently 
continues to pour out a small 
amount of secretion. This be- 
comes inspissated and collects 
most frequently in the upper 
and posterior quadrant directly 
over the stapes, and sometimes 
seriously interferes with the 
movements of the ossicle (Fig. 
115). Those cases which suffer 
from frequently recurring at- 
tacks of congestion of the lining 
membrane of the middle ear 
with the production of a slight amount of discharge are prone 
to suffer from the development of exuberant granulations in 
the various portions of the tympanic cavity. This is particu- 




Fig. 115. — Inspissated secretion mixed 
with cerumen, covering a small 
perforation in the supero-posterior 
quadrant. 



SYMPTOMATOLOGY. 435 

larly true where proper attention is not paid to cleanliness, 
the continued action of heat and moisture favoring the devel- 
opment of exuberant granulations. 

Symptomatology. — The symptoms to which these changes 
give rise consist usually in an impairment of function of the 
organ, either to a considerable extent or only to a slight de- 
gree. As we have said before, impairment in hearing follow- 
ing purulent inflammation is less marked than when it occurs 
as the result of a nonsuppurative inflammation. The pres- 
ence of subjective noises is not a symptom of as much im- 
portance in these cases, as they are seldom so prominent as 
to give serious discomfort, and unless specially inquired into 
may not be mentioned by the patient himself. Attacks of 
giddiness are occasionally complained of, usually following 
some manipulation about the ear, such as the insertion of 
some instrument into the canal for cleansing it, or the use of 
the syringe. In these instances we usually find that the head 
of the stapes is exposed. From the above classification of 
the affection we are now considering no discharge is present 
in these cases. The canal, however, is seldom perfectly free 
from foreign material. The exposed mucous membrane ex- 
foliates its superficial epithelium, which accumulates within 
the meatus, or adheres to the walls as thin yellowish-white 
or brownish scales. These masses frequently adhere quite 
firmly to the walls of the meatus, and upon separating them 
a denuded area remains. The presence of this desquamated 
material, together with the moisture normally present in the 
canal, favors the development of the various forms of asper- 
gillus, causing a slight discharge, or in severe cases an acute 
external otitis, with the attendant symptoms of pain, etc. 
The hearing is usually fairly constant, any variation from 
this condition being coincident with congestive changes in 
the upper air passages, as when the individual suffers from 
an acute coryza or from an acute naso-pharyngitis. 

The development of cholesteatoma may manifest itself in 
cases which have remained quiescent for a long period. In 
certain cases the superficial epithelium of the canal migrates 
into the tympanic cavity and replaces the pavement epithelium 
of the mucous membrane. These epidermal cells are devel- 
oped with unusual rapidity and as quickly thrown off. As 
the result, the tympanum is filled with a mass of epithelial 
cells which steadilv increases in size and exerts great pressure 



436 OTITIS MEDIA PURULENTA RESIDUA. 

upon the surrounding bony walls. The mastoid cells at a 
later period are invaded. The partitions between the pneu- 
matic spaces are broken down, converting this series of small 
cavities into one large cavity. 

Such a mass may produce no distinctive symptoms until 
the tympanum becomes acutely inflamed from some cause, 
when the sudden increase in volume due to the absorption 
of the products of the inflammatory process induces acute 
symptoms referable to the mastoid or middle ear. 

Where a suppurative inflammation has existed for a long 
time a condensing osteitis of the mastoid not uncommonly 
occurs. This may continue after suppuration in the tym- 
panum has ceased. The mastoid then becomes the seat of in- 
tense pain, either constant or paroxysmal, while neither the 
mastoid nor middle ear presents any evidence of acute inflam- 
mation. The possibility of such a process should always be 
borne in mind when persistent neuralgia of the mastoid region 
is met with in a subject who has suffered from a purulent 
otitis at any previous period. 

In this connection it might be mentioned that in any case 
of persistent facial neuralgia of obscure origin the ear should 
always be examined. 1 have found in cases coming under 
observation for some aural affection, that frequently the treat- 
ment of the ear has arrested the attack of facial neuralgia, and 
the patients have of their own accord asseverated the facts. 

It should be remembered that a suppurative inflammation 
in early infancy may leave no evidence in adult life except a 
minute pit or opening above the short process of the malleus. 
In these cases in particular the remains of the former affec- 
tion may produce the symptoms in question. 

Diagnosis. — A. Physical Examination. — The condition, as 
revealed by an examination of the parts, is of but little serv- 
ice in estimating the degree of impairment of hearing, or 
the relation between this impairment and the trouble present 
in the middle ear. It is only by a thorough functional exami- 
nation in connection with minute ocular inspection that we 
can correctly judge as to how much of the interference with 
function depends upon the changes within the tympanum, as 
distinguished from that caused by the labyrinthine involve- 
ment. 

B. Functional Examination. — Where the middle ear alone 
is affected, the examination by means of musical tones and 






FUNCTIONAL EXAMINATION AND PROGNOSIS. 



437 



the ordinary tests for hearing- yields results characteristic of 
obstruction to sound conduction. These are elevation of the 
lower tone limit, very slight lowering of the upper tone limit, 
or no deviation from the normal standard, increased bone 
conduction, and, if one side alone is affected, a lateralization to 
the affected side of the vibrating tuning fork held upon the 
forehead in the median line. Moreover, the impairment is 
usually relatively greater for the voice than for sharp sounds, 
such as those of the watch or acoumeter. The degree of 
impairment for spoken or whispered words is proportionate 
to the height, in the musical scale, to which the relative dura- 
tion of air and bone conduction is reversed, the inversion 
extending to the upper notes when the degree of impairment 
is marked, but affecting only the lower portion of the scale 
when this impairment is but moderate. 

When the labyrinth has become involved we have, in ad- 
dition to the evidences of interference with sound conduction, 
certain signs characteristic of changes in the lower portion of 
the cochlea. The upper tone limit is almost invariably low- 
ered to a marked extent, usually below 20,000 V. D. Where 
the elevation of the lower tone limit remains the same as in 
uncomplicated cases, absolute bone conduction is usually 
diminished, and this is always the case when serious labyrin- 
thine involvement is present. Occasionally it may be normal 
or increased. The tuning fork held upon the vertex is sel- 
dom lateralized to the poorer ear. The important diagnostic 
test is an observation of the relation between the impairment 
for whispered or spoken words and the position in the musi- 
cal scale at which the reversal between air and bone conduc- 
tion ceases. It will be found that where impairment is due 
chiefly to labyrinthine changes the impairment of hearing 
will be very marked, while the ratio between air and bone 
conduction will be reversed only for the very lowest notes. 
In such instances, even if the abnormal tension in the sound- 
conducting mechanism can be corrected, sufficient changes 
have taken place in the perceptive apparatus to render these 
measures of but little value in improving the hearing. 

Prognosis. — The disease under discussion is usually more 
amenable to treatment than any other form of chronic tym- 
panic inflammation. If left to itself, the majority of cases 
either do not progress at all, or deterioration is so slow as to 
enable us to promise that it will cause but little increased in- 



438 OTITIS MEDIA PURULENTA RESIDUA. 

convenience in the future. A certain proportion of these 
cases improve spontaneously. This is particularly true in 
children or young adults, the continued massage of the parts 
by the sonorous vibrations to which they are subjected 
gradually stretching the adhesions or causing their resorp- 
tion. After the age of thirty or thirty-five this probably never 
takes place spontaneously. After proper treatment the con- 
dition seldom recurs, and any improvement is likely to be 
permanent, it being more probable that the condition will 
even improve in subsequent years. The degree of improve- 
ment to be attained depends more upon the degree of laby- 
rinthine involvement than upon any other one circumstance. 
If this is considerable, measures directed toward the middle 
ear probably aggravate the condition rather than benefit it. 
This is specially true of surgical measures. Certain cases 
come under observation on account of a sudden impairment 
of audition, and examination may reveal serious interference 
with the labyrinth. Where these changes are recent, meas- 
ures directed to the middle ear are not contraindicated, since 
the disturbance within the labyrinth may depend upon some 
recent change in the sound-conducting mechanism which has 
not advanced to such an extent as to render the removal of 
the cause ineffectual in relieving the condition. 

Treatment. — Where the symptoms depend upon swelling 
of the mucous membrane, measures directed toward the regu- 
lation of the habits of life especially are among the first indi- 
cations. Next, the condition of the upper air passages should 
be thoroughly investigated and any obstructive condition 
corrected. This is particularly true where functional exami- 
nation indicates labyrinthine interference, on account of the 
intimate relation between the venous return current from the 
labyrinth and that from the nasal passages. If these meas- 
ures are not successful, topical applications to the lining 
membrane of the middle ear are to be instituted. These 
should be of mildly astringent character at first, the strength 
being increased if necessary. It is interesting in this connec- 
tion to remark that although the membrana tympani may be 
almost completely destroyed, a restoration of the lumen of 
the Eustachian tube to its normal calibre will frequently re- 
lieve the symptoms. This depends, no doubt, upon the re- 
moval of obstruction to the venous return current from the 
tympanum. The condition within the Eustachian tube either 



TREATMENT. 



439 



may yield to simple inflation or may demand the use of some 
stimulating vapors, and in the more severe cases it may be 
necessary to resort to the bougie. 

We should never lose sight of one fact, and that is the ex- 
treme susceptibility of these cases to the development of one 
of the vegetable molds. This may keep up a chronic conges- 
tion of the lining membrane of the middle ear in spite of the 
treatment already mentioned, and we should always be cer- 
tain that the meatus is in a fairly aseptic condition in order 
that this factor may be eliminated. Where hypertrophic 
changes are more extensive and small aggregations of newly- 
formed tissue are found in any locality, these may be de- 
stroyed in situ either by the potential cautery or by chemical 
agents, but they are seldom large enough to be removed by 
means of the curette or snare. Occasionally a small crust 
will develop in the upper posterior quadrant, directly over 
the region of the oval or round windows, preventing the 
transmission of aerial vibrations to the labyrinthine fluid. 
Such an obstruction may be removed by the forceps, curette 
or syringe, as seems indicated in the particular case. It 
should be remembered that the removal of such a mass may 
be followed by a recurrence of the discharge, and it is wise 
to mention this fact to the patient before operating. 

Where the tense margin of a remnant of the membrana 
tympani displaces the ossicles in any manner, the division 
of the fold by means of the knife is frequently followed by an 
astonishing improvement in function. The section can be 
made under cocaine anaesthesia, and if proper aseptic precau- 
tions are observed in preparing the field of operation, the pro- 
cedure is followed by no discomfort. It is frequently neces- 
sary to repeat the section several times, the parts reuniting 
after division. They do not, however, unite throughout the 
entire length of the incision, and by repeating the procedure 
the tension is gradually relieved. When an obstructing band 
can not be exactly located in those cases where the entire 
ossicular chain remains, and other measures have failed to 
effect the desired improvement, it is wise to remove the re- 
mains of the membrana tympani, together with the two 
larger ossicles, thus exposing the round window and the 
stapes, the latter ossicle being dealt with according to the 
condition found upon inspection. This plan is advocated 
after considerable practical experience in cases of this char- 



440 OTITIS MEDIA PURULENTA RESIDUA. 

acter ; and although relief is sometimes obtained by dividing 
rather blindly various constricting bands which lie beyond 
the field of vision, but are known to be present from the posi- 
tion which the ossicles assume, we seldom obtain sufficient 
amelioration to be satisfactory either to the surgeon or to the 
patient, and at length resort to the more complete opera- 
tion already mentioned. It is wise, therefore, to make this 
the operation of election, and to eliminate thoroughly all 
interference with tension in the conducting chain at a single 
operation. 

Where the stapes is exposed, the incudo-stapedial articula- 
tion having been destroyed, several plans of treatment are 
open to us. The simplest is auto-mobilization, by inserting 
an artificial drum membrane, such as a small disk of paper or 
a small pledget of cotton. This is applied with the forceps 
or cotton holder, so as to rest upon the head of the stapes, and, 
by increasing the surface presented for the reception of aerial 
vibrations, causes them to exert a more powerful force upon 
the stapes. Decided improvement has followed this plan in 
several cases. Where manipulation by means of the probe 
shows that the stapes is firmly fixed, it is well to break up 
these adhesions by manipulation, the knife being employed to 
divide the more dense bands if necessary. The technique of 
these operations will be described in a chapter devoted to 
the operative surgery of the middle ear. 

Concerning the advisability of the extraction of the stapes 
good results have been obtained in these residuary cases. It 
is a question in my mind, however, whether we can not obtain 
similar, or even better, results by leaving the stapes in place 
and mobilizing it mechanically ; for, although I have removed 
it a number of times with good results, I have, in cases pre- 
senting similar symptoms and responding in the same manner 
to functional tests, seen no improvement whatever follow the 
operation. If the entire stapes can be removed, it can cer- 
tainly be mobilized, and the foot plate probably transmits the 
sonorous waves to the labyrinth more perfectly than does the 
cicatricial membrane which is formed after its removal. 
Where ossification at the stapedio-vestibular articulation has 
taken place, the removal of the part piecemeal may be at- 
tempted. This procedure is effected either by means of a 
sharp spoon or by a small burr, which wears away the thin, 
bony lamella separating the labyrinth from the tympanum. 



TREATMENT. 441 

The burr should be conical in shape and so guarded as to 
prevent its entering the labyrinth more than a millimetre, 
when the foot plate is perforated. 

Adhesions about the round window can seldom be seen, 
but their presence may be suspected when the niche of the 
fenestra rotunda is surrounded by hypertrophied mucous 
membrane. Stellate incision, by means of an angular knife 
inserted into the niche, will relieve tension here, and is fre- 
quently followed by improvement in connection with opera- 
tive procedures about the oval window. Concerning any 
aggravation of symptoms which surgical measures may in- 
duce, I can only say that their occurrence is very rare, if we 
bear in mind the rule that when serious labyrinthine disturb- 
ance is present operative measures are contraindicated. 

Where the labyrinth is involved the internal administra- 
tion of pilocarpine often relieves the tension and is followed 
by an amelioration of the symptoms. After this has occurred, 
if functional examination indicates that the tympanic lesion is 
a competent cause of the interference with function, opera- 
tive measures now become proper. Where the residual con- 
dition is present in but one ear, the effect upon the organ of 
the opposite side is always to be borne in mind. If the oppo- 
site ear becomes affected, the changes first met with are usu- 
ally labyrinthine in character, and operative measures may be 
indicated for the preservation of the sound organ, although the 
ear operated upon may be beyond relief. It is sometimes 
stated that interference in these residuary cases may be fol- 
lowed by a recurrence of the discharge, but it has never been 
my experience to witness this. A discharge from an ear 
which is the seat of a residual process can depend only upon 
the presence of some foreign body ; and no operative meas- 
ures, if properly carried out, would lead to the development 
of this condition — that is, to the development of bony ne- 
crosis. 



30 




IV. DISEASES OF THE MASTOID PROCESS. 
CHAPTER XXIV. 

THE ANATOMY OF THE MASTOID PROCESS. 

In considering the anatomy of the ear a detailed descrip- 
tion of the mastoid process was not given, it seeming wiser 
to incorporate the necessary details in the section on Diseases 
of the Mastoid. The mastoid portion of the temporal bone 
is an irregular conical mass of osseous tissue located behind 
the external auditory meatus and projecting for a varying 
distance below the level of its floor. Its lower extremity, 
forming the apex of the cone, is covered by the aponeurosis 

of the sterno-mastoid 
IfclD^? muscle. This muscle 

^ f&'fNt •£* *" ; * s attached not only to 

the tip of the process, 

.* ; * f, ' *'* lid but also for a consider- 

i / ' v \ able distance along its- 

s * f $- / '*'•* internal aspect. Above 

the insertion of the 

*-*/ muscle upon the inter- 

FIG. n6.-The pneumatic mastoid. The section n *} SUrfaCe ° f the maS " 

shows the relative position of the tympanic vault toid is a deep furrow,, 

and mastoid antrum to each other and to the f i j • . • 

intracranial surface. (Author's specimen.) tne < OlgastriC groove,. 

which lodges the oc- 
cipital artery and furnishes attachment for the posterior head 
of the digastric muscle. This bony mass may be pneumatic, 
diploic, or sclerotic in structure. In the pneumatic mastoid 
(Fig. 1 16) there are numerous air spaces throughout the entire 
mass ; these are irregularly distributed, in some cases lying 
almost immediately below the cortex, while in other instances 
they are situated at considerable depth below the outer sur- 
face of the bone and are specially numerous upon its anterior 
aspect ; this anterior wall of the mastoid forms the posterior 

(442) 





VARIATIONS IN STRUCTURE. 443 

wall of the external auditory canal, and when the cells are 
well developed in this region the earliest evidences of their 
involvement in an inflammatory process appears here. One 
pneumatic space is constant, and that is the antrum. This cav- 
ity is irregularly pyramidal in shape, communicates with the 
tympanic vault by a narrow passage, and varies considerably 
in size in different individuals. At birth the antrum is the 
only space developed, the others being formed subsequently. 
We not infrequently find a second cell of considerable size 
located at the very tip 
of the process ; the out- " ^HH 
er bony wall of this jE 
space is often very thin 
— a fact which is of con- 
siderable clinical im- i 
portance. 

In the diploic mas- 
toid the antrum alone \ H^ 

is present, the remain- ^ ^%^^ 

r . . Fig. 117. — Diploic mastoid, 

ing portion consisting 

of diploic tissue, similar to that found in the other cranial 

bones (Fig. 1 17). 

Where the mastoid is sclerotic the entire process consists 
of a dense eburnated mass of osseous tissue ; its structure is 
uniform throughout, presenting not even the slightest vestige 
of a pneumatic space, with the exception of the antrum, and 
even this may be of small size. 

Various combinations of these three forms may be met 
with in individual cases ; thus a sclerotic process may have 
progressed to a certain point and ceased spontaneously, in 
which event the trabecular will be firmer than normal and 
the pneumatic spaces of small size ; or but one or two air 
cells may exist, the remaining portion being diploic in struc- 
ture. 

Owing to the invariable presence of the mastoid antrum, 
its location is a matter of importance. It is best located by 
bearing in mind its relation to the superior and posterior walls 
of the external auditory meatus. If two lines be drawn — one 
horizontal, tangent to the superior wall of the external audi- 
tory canal, the second vertical and tangent to its posterior 
wall — the point of their intersection will be the apex oi a tri- 
angle the base of which will be formed by that portion of the 



444 



THE ANATOMY OF THE MASTOID PROCESS. 




Fig. 118. — Horizontal section through a pneu- 
matic mastoid, s, Groove for lateral sinus ; 
a, Mastoid antrum ; t, Tympanic cavity ; g, 
Posterior wall of external canal ; w, w\ Path 
of instrument from surface of mastoid to 
antrum. (Politzer.) 



curvilinear outline of the meatus included between the points 
of tangency of these lines. This triangle lies immediately 

over the antrum and an 
artificial opening within 
this space will enter the 
cavity. 

Another cell which 
is fairly constant is that 
large pneumatic space 
located at the tip of the 
apophysis. The outer 
bony wall of this cavity 
on the digastric surface 
of the mastoid is often 
no thicker than parch- 
ment, and where the mas- 
toid is the seat of an in- 
flammatory process at- 
tended by the formation 
of pus, the involvement of this large space may be first evi- 
denced by the presence of diffuse tumefaction near the mastoid 
origin of the sterno-mastoid muscle, either on the external sur- 
face or more usually in the digastric fossa, in which case the 
tumefaction lies immediately beneath the body of the muscle. 

The relation which the mas- 
toid bears to the intracranial 
contents is of importance in the 
performance of surgical opera- 
tions in this region. The to- 
pographical relations between 
the mastoid and the tympanum 
and cranial fossae are best con- 
sidered together, since operative 
procedures upon the mastoid 
process are usually demanded 
because of some abnormal con- 
dition within the tympanum, 
and this cavity is always entered 
at the time of operation. The 
roof of the tympanum is formed by the petro-squamous suture 
and supports the temporo-sphenoidal lobe of the cerebrum. 
The vault of the tympanum and mastoid antrum, then, are in 




Fig. 119. — a, Mastoid antrum; s, 
Groove for lateral sinus ; g, Pos- 
terior wall of external canal ; w,w , 
Path of instrument from surface of 
mastoid to antrum. (Politzer.) 



RELATIONS WITH THE CRANIAL CONTENTS. 



445 



relation above to the middle cranial fossa ; hence any product 
of inflammation passing through the roof of the tympanum 
enters this portion of the cranial cavity, after which its con- 
veyance along the superior surface of the petrous portion of 
the temporal bone to the region of the medulla is exceedingly 
simple. As the mastoid antrum is but an extension backward 
of the vault of the tympanum, its intracranial relations are 
the same as are those of the tympanic vault. The mastoid 
cells are also in relation with the meninges of the posterior 
cerebral and the cerebellar fossae. In cases of intracranial 
involvement complicating mastoid inflammation, the process 
is usually confined to meninges covering the posterior cere- 
bral lobe or the cerebellum. When extension takes place 
through the roof of the tympanum the contents of the middle 
cranial fossa is usually involved. 

The internal surface of the mastoid process presents a deep 
groove for the lodgment of the lateral sinus. The distance 
which this vessel may extend into the mastoid varies in indi- 
vidual cases ; usually it lies be- 
hind the antrum, and in some 
instances the bend of the sinus 
is so sharp that the acute angle 
extends forward so as to lie but 
a short distance behind the pos- 
terior wall of the external audi- 
tory meatus, and may be so near 
the surface of the process as to 
cover the antrum (see Fig. 120). 
It is evident that with the sinus 
in this position an artificial open- 
ing into the antrum could not 
be made at the site of election 
for entering this cavity without 
exposing or wounding this large 
venous channel. In Fig. 118 the parts are so placed that the 
sinus is in no danger, while in Fig. 119 it could be avoided 
with care. 

An examination of numerous specimens has been made 
by both Korner * and Randall f for the purpose of determin- 




Fig. 120. — t, Tympanic cavity ; u, 
Floor of external meatus ; s, Gioove 
for lateral sinus ; w, u>' , Path of in- 
strument from surface of mastoid to 
antrum. In this case the sinus would 
be wounded in the operation. (Po- 
litzer.) 



* Arch, of Otol., vol. xviii, p. 310. 

\ Trans, of the Amer. Otol. Society, 1S92, p. 235. 



446 THE ANATOMY OF THE MASTOID PROCESS. 

ing whether the location of the sinus could be positively de- 
cided by external measurements of the skull. These re- 
searches prove conclusively that external measurements are 
useless in determining the site of the sinus. This venous 
channel, then, bears an important relation to the mastoid pro- 
cess, and its variable situation must always be borne in mind 
in operative procedures. When, for any reason, it seems de- 
sirable to expose the sinus during an operation, it can be done 
by extending the opening in the bone backward, care being 
taken to avoid the removal of any bone beyond the occipito- 
temporal suture. The groove lodging the knee of the sinus 
is located in the mastoid process, and an extension of the open- 
ing to the point of junction between the occipital and temporal 
bones affords abundant space for examination of the sinus as 
well as of the condition of the posterior cranial fossa both 
above and below the tentorium. This statement regarding 
the extensive removal of bone in exposing the sinus may 
seem unnecessary, but where the patient is anaemic the ex- 
posed sinus may be nearly empty and its walls may be of the 
same color as the contiguous meningeal surface, rendering its 
recognition difficult. 

From the presence of this vessel it is advisable in all oper- 
ations upon the mastoid first to remove the cortex as close to 
the posterior wall of the canal as possible. After the cells 
are entered and the topography of the particular process is 
ascertained, the opening may then be enlarged as much as is 
necessary, but the cavity should always be entered as close 
to this line as possible. 

In the majority of cases the middle cranial fossa lies at a 
considerably higher level than the horizontal plane passing 
through the superior wall of the bony meatus. The location 
of the floor of this space is commonly above the plane pass- 
ing through the temporal ridge, this last term being applied 
to the prolongation of the roof of the zygoma backward 
over the entrance of the external auditory canal. The tem- 
poral ridge was for a time considered the upper limit of 
safety in opening the mastoid process. Occasionally, how- 
ever, we meet with cases in which the squamous portion of 
the temporal bone, instead of lying almost vertical, is consid- 
erably inclined, forming an acute angle with the horizontal 
plane. When this occurs the temporal ridge overhangs the 
entrance to the meatus (Fig. 121). Unless care is exercised, 



DEVELOPMENTAL CHANGES. 



447 




the superior margin of the canal will not be correctly located, 
the prominent ridge being mistaken for it. It will easily be 
seen that if the chisel is now applied over what seems to be 
the area ordinarily 
selected for perfo- 
rating the cortex, the 
opening will be situ- 
ated above the mas- 
toid antrum, and the 
middle cranial fossa Jm 
will be entered. Care 
should be taken, 
therefore, to recog- 
nize this anomaly, 
and to be certain 
that the superior 
margin of the canal 
is really exposed be- 
fore the bone is per- 
forated. In young 
children this promi- 
nence of the tem- 
poral ridge is a usual 
condition, owing to 

the exceedingly oblique angle between the squama and the 
auditory plate (Figs. 6 and 122). 

In the infant at birth the mastoid is but poorly developed, 
consisting usually of but a single cell — the antrum. It must 
be remembered, however, that there is a very large pneumatic 
space in immediate relation to the tympanic cavity, as the 
vault of the tympanum in the child is nearly as large as in 
the adult, the ossicles increasing but little in size from the 
period of birth to adult life. This, no doubt, explains the 
cause of the pronounced symptoms found in even the simpler 
inflammations of the middle ear in infancy and early child- 
hood. The inner table of the cranium is excessively thin, 
and frequently incomplete in places along some of the sutural 
lines. The vascular supply of the lining membrane of this 
pneumatic space, made up of the vault of the tympanum 
and of the mastoid antrum, is very free and in close anasto- 
motic relation with the intracranial venous sinuses. For this 
reason symptoms of meningeal irritation are frequently ob- 



Fig. 121. — Adult temporal bone in which the tem- 
poral ridge overhangs the entrance to the canal. 
(Author's specimen.) 



448 



THE ANATOMY OF THE MASTOID PROCESS. 



served, even in a mild attack of otitis media in infancy. 
Again, a fatal termination is probably more common than we 
are aware, due to an early thrombosis of the venous sinuses, 
or to septic meningitis. These may occur even before dis- 
charge appears in the external auditory meatus, and perhaps 
without special attention having been called to the ear, unless 
the physician is aware of the fact that one of the most fre- 
quent causes of high temperature in young infants is a middle- 
ear inflammation. A reference to Fig. 122, which is a draw- 
ing of a specimen in the posses- 
sion of the author, shows how 
capacious this pneumatic space 
may be at birth. 

The depth at which the mas- 
toid antrum lies varies in differ- 
ent cases. It is seldom entered 
at a depth of less than half an 
inch, and may lie seven eighths 
of an inch below the external 
surface. The only structure of 
importance lying within the mas- 
toid process itself is the facial 
nerve, which passes out through 
the stylomastoid foramen. The 
nerve crosses the upper portion 
of the tympanic cavity in the 
aquseductus Fallopii, and leaves 
the cavity through an opening 
in the posterior wall. In the mastoid its course is downward, 
outward, and slightly backward, crossing the line of the pos- 
terior canal wall at the junction of the lower and middle 
third. Since it is deeply placed and the bony wall covering 
it is so dense, it is seldom wounded, and a little care will 
enable the operator to avoid it. Immediately above the 
aquseductus Fallopii we find the horizontal semicircular canal. 
This structure can be injured only by continuing the artificial 
opening beyond the level of the internal wall of the tym- 
panum, an accident which need not occur if ordinary care is 
exercised. The same may be said of wounding the facial 
nerve in its passage through the aqueduct. 




Fig. 122. — The tympanic vault and 
mastoid antrum at birth, #, Ex- 
ternal canal separated from sur- 
face of squama. At its inner 
extremity is the membrana tym- 
pani inclosed by the tympanic 
ring. Above the ring the mal- 
leus and incus are plainly seen. 
(Author's specimen, natural size.) 



CHAPTER XXV. 

INFLAMMATION OF THE MASTOID PROCESS. 

iEtiology. — The most common cause of an acute inflam- 
mation in this region is an extension of a similar process from 
the middle ear. The primary lesion may be either acute or 
chronic in character, although it is probable that a simple 
catarrhal inflammation does not involve the mastoid process 
by extension. In cases where the mastoid is involved, during 
the course of what has seemed to be a catarrhal inflammation, 
it is believed that the process within the middle ear has al- 
ready changed in character and that the involvement of the 
mastoid has occurred at a very early stage on account of the 
intensity of the process, which has attacked not only the mid- 
dle ear, but the communicating pneumatic chamber as well. 

Primary mastoiditis, although uncommon, is occasionally 
seen, and may follow an exposure to cold or a traumatism, or 
may be a manifestation of a tubercular or specific diathesis. 
This last condition is probably the most common cause of a 
primary mastoid inflammation, a gummatous deposit occur- 
ring and subsequently breaking down in the characteristic 
manner. Inflammatory conditions within the meatus may also 
extend to the mastoid by contiguity. A simple circumscribed 
inflammation may produce this result, especially when located 
upon the posterior wall of the canal. Diffuse external otitis 
may cause a similar condition. Chronic suppurative inflam- 
mation of the middle ear is the most common cause of an 
acute mastoiditis. It seems curious that, from the intimate 
relation w^hich exists between the mastoid cells and the tym- 
panum, the latter cavity may be the seat of a purulent in- 
flammation for years without producing a similar condition 
within the mastoid. From some slight cause, frequently so 
trivial in character as to be unrecognized, infection in this 
region occurs, terminating in extensive destruction of the 
osseous tissue. 

(449) 



45o 



INFLAMMATION OF THE MASTOID PROCESS. 



Pathology. — A chronic purulent otitis media causes cer- 
tain changes within the mastoid, attended by a thickening of 
the membrane lining the cells and an increase in the vascu- 
larity. These changes, continuing, lead to a deposit of new 
osseous tissue, which, in the most marked cases, converts the 
entire process into a mass of compact bone of ivorylike con- 
sistence and obliterates the cells completely. 

Again, instead of a hypertrophic change, a local necrosis 
may result. If this affects a large area, a sequestrum is formed, 
which is either exfoliated spontaneously or demands operative 
measures for its removal. If the destruction takes place over 
but a limited area, the disintegrated tissue is discharged as 
pus ; when moderate in amount and a free exit is afforded 
through the external auditory canal, the copious discharge 
from the canal may be the sole evidence of the involvement 
of the mastoid cells. If, however, drainage is not free, symp- 
toms of pus retention are manifested. 

The presence of infectious material within the bony cavity 
may produce several results ; the simplest, already mentioned, 
is a copious otorrhcea. If drainage through the canal is im- 
peded, the fluid must find exit, and evacuates itself spontane- 
ously where the least resistance is offered. This may be — 

i. Through the external mastoid cortex, either behind the 
ear or in the external meatus. 

2. Through the cortex in the digastric fossa. 

3. Through the roof of the antrum, or of the tympanic 
vault, into the middle cranial fossa. 

4. Into the posterior cranial fossa, usually by rupture into 
the groove lodging the lateral sinus. 

When the cranial cavity is invaded we have an inflamma- 
tion of the meninges, which may be diffuse or circumscribed. 
In the former condition a purulent leptomeningitis results, 
while in the latter an epidural abscess is formed. The pro- 
duction of an epidural abscess seems to be an effort on the 
part of Nature to limit the inflammation to a circumscribed 
area, the infectious material being walled in on all sides by 
adhesions between the dura and the adjacent osseous walls. 
Internal rupture is not the only manner in which the contents 
of the cranial cavity may be invaded ; the free anastomosis 
between the blood vessels of the dura and the pericranium 
may furnish the avenue through which the infectious material 
may pass to the intracranial contents. In this manner we 



INTRACRANIAL COMPLICATIONS. 45 I 

may have, in addition to the two conditions already men- 
tioned, a thrombosis of the lateral sinus, or an abscess within 
the brain substance. Unfortunately for the patient, these 
lesions, instead of being single, frequently occur together ; 
thus a sinus thrombosis without considerable meningitis is 
rare, while a brain abscess is a not infrequent accompaniment 
of thrombosis of the sinus. 

Where rupture takes place upon the external surface of 
the mastoid, it is commonly supposed that all serious danger 
of involvement of the intracranial contents is at an end, al- 
though the abscess may not be immediately evacuated by in- 
cision of the overlying soft parts. This is an error, particu- 
larly in the case of children. Here the sutural lines between 
the various portions of the temporal bone are not completely 
ossified, and when the external surface of the temporal bone 
is bathed in pus, infection, either through the sutural lines or 
through the substance of the squama itself, is by no means 
impossible. 

I have reported one case of this character in a child and 
one in an adult,* while several other instances may be found 
in otological literature. In children the presence of pus be- 
neath the integument in the post-aural region does not of ne- 
cessity indicate a perforation through the cortex. In these 
young subjects a collection of fluid within the tympanic vault 
frequently makes its way along the superior wall of the canal, 
gaining exit from the cavity through the Rivinian segment 
by dissecting the soft parts away from the bone in this loca- 
tion. In very young infants this is by no means uncommon, 
while in children over ten years of age it is occasionally met 
with. Perforation of the cortex on the anterior surface — that 
is, through the posterior wall of the bony meatus — may occa- 
sionally occur. Spontaneous evacuation here is probably due 
to the fact that in the particular case the external cortex is 
thicker, while along the posterior aspect of the canal the 
pneumatic cavities are well developed and thin-walled. Where 
sequestra are formed the process does not differ, except that 
in addition to the fluid collection we have a foreign body 
whose action is to aggravate the changes already described. 
The same remark applies to the development of a cholestea- 
tomatous mass within the mastoid cells. These epithelial col- 

* Archives of Otology, vol. xxi, p. 253. 



452 INFLAMMATION OF THE MASTOID PROCESS. 

lections are rather prone to excite a hyperplastic inflamma- 
tion, terminating- in sclerosis with obliteration of the trabecular 
between the cells. It is only when the mass attains consider- 
able size that acute inflammatory changes are set up, produc- 
ing a train of symptoms characteristic of an acute process in 
this region. 

The cholesteatomatous deposit may attain such a size as to 
cause absorption of the posterior wall of the canal, converting- 
the mastoid, antrum, tympanum, and bony meatus into a single 
cavity. At the same time the cortex of the mastoid is often 
sclerosed. 

Symptomatology. — The prominent symptom met with is 
intense pain over the mastoid portion of the temporal bone. 
The pain is particularly severe at night, preventing sleep. It 
is of dull character, deep-seated and constant. Following a 
painful inflammation within the tympanum, a change in the 
character and location of the pain complained of by the pa- 
tient is a valuable symptom. The degree of constitutional 
disturbance presented is often entirely out of proportion to 
the local changes. The patient may be well nourished, the 
temperature normal, and the pulse but slightly accelerated, 
while at the same time extensive destruction is taking place. 
Where the disease complicates an acute process within the 
middle ear, or is primary in character, the temperature is 
usually elevated, varying from 99. 5 to 101.5 , but seldom 
higher than this. An extension of the pain to the temporal 
region is rarely complained of, its location being limited to the 
mastoid process. Where the cells are well developed at the 
apex, considerable difficulty may be experienced in moving the 
head from side to side. In children this symptom should al- 
ways be carefully investigated, although no pain may be com- 
plained of in the region of the ear. Tenderness upon deep 
pressure is probably the most characteristic sign of the in- 
volvement of the osseous structures. This varies considerably 
in location. It is usually most marked directly over the an- 
trum and close to the posterior margin. of the canal. Occa- 
sionally the most tender point will be found at the tip of the 
apophysis. Where a previous aural discharge has been pres- 
ent, the access of the symptoms referable to the mastoid is 
frequently accompanied by a cessation of discharge from the 
canal or by a diminution in the amount. In young children 
who are unable to locate exactly the seat of pain, restlessness 



SYMPTOMATOLOGY— INTRACRANIAL INVOLVEMENT. 453 

at night should always excite suspicion if it follows the cessa- 
tion of a profuse aural discharge. Tumefaction behind the 
auricle is not common, except in early life. GEdema of the 
overlying soft parts is more characteristic of an inflammation 
within the canal than of involvement of the mastoid process. 
Fluctuation, it need hardly be said, indicates spontaneous 
evacuation of the purulent contents. 

If the intracranial structures are involved, the symptoms 
manifested depend upon the particular region attacked. If 
one of the large venous sinuses becomes the seat of an infec- 
tious thrombus, the temperature changes are the most charac- 
teristic evidence of the condition. They consist in the sud- 
den elevation of the temperature, the thermometer frequently 
registering 104 or 105 . . This elevation persists but for a few 
hours, and is followed by a spontaneous fall to the normal 
standard or even lower than this. These intermittent eleva- 
tions may occur several times during the day, and may be of 
such short duration as to be unrecognized unless the tempera- 
ture is taken frequently. Following the access of the fever 
there is profuse perspiration, and as the condition advances, 
well-marked symptoms of general sepsis appear. The patient 
becomes very weak. The skin is of a dull, ashy hue, the 
pulse feeble, and the mental condition dull, all of which are 
indicative of profound systemic infection. If emboli are de- 
veloped, their lodgment in the various viscera is followed by 
characteristic symptoms. The most common site of lodgment 
is probably the lungs, causing a septic pneumonia. When the 
thrombus develops in the lateral sinus it frequently extends 
downward into the internal jugular vein, and its presence is 
revealed by deep tenderness along the course of this vessel, 
together with tumefaction along the anterior border of the 
sterno-mastoid muscle. Whenever temperature changes ex- 
cite suspicion of involvement of the sinus, the region of the 
external jugular vein should be examined frequently for con- 
firmatory signs. The sensorium is seldom disturbed, except 
just before death, where thrombosis alone is present. 

Where involvement of the intracranial structures results 
in diffuse meningitis, we have intense headache, photophobia. 
a high temperature which remains constant, nausea, and 
vomiting. Otitic meningitis usually involves the base of the 
brain rather than the convexity. Hence a slow pulse charac- 
teristic of traumatic meningeal inflammation is wanting, the 



454 



INFLAMMATION OF THE MASTOID PROCESS. 



cardiac action being increased in rapidity. Paralysis of in- 
dividual muscles soon appears, the third and sixth nerves 
being most frequently involved, causing either strabismus or 
paralysis of the ciliary muscle. Rigidity of the muscles of 
the neck occurs quite early, and is one of the most character- 
istic symptoms. 

Where the meningitis is localized, constituting an extra- 
dural abscess, the temperature is usually but moderately 
elevated, seldom exceeding ioo°. The characteristic sym- 
tom is localized headache, the painful region corresponding 
pretty closely to the area involved. Paralytic symptoms do 
not appear until late in the course of the disease. Rigidity 
of the muscles of the neck, vomiting and photophobia are 
also absent. 

The occurrence of an abscess within the cerebral sub- 
stance is a rare accompaniment of acute mastoid inflammation. 
It may be said it produces no symptoms which may be called 
characteristic until it has attained sufficient size to press upon 
some portion of the motor tract. Its presence should always 
be suspected when there is a persistent low temperature, to- 
gether with constant headache, increasing asthenia, and pro- 
gressive hebetude. So far from producing characteristic 
symptoms, it is rather the absence of any characteristic mani- 
festation, but the failure of the patient to improve, which 
should always excite suspicion of this condition. When in 
an acute mastoiditis the pain diminishes in severity and as- 
sumes the character of a general headache, while at the same 
time the patient becomes progressively dull and unobservant 
of his surroundings, the temperature remaining normal or but 
slightly elevated, invasion of the cerebral substance should 
be suspected. The occurrence of two or more of these intra- 
cranial conditions in association is what renders a diagnosis 
difficult. A brain abscess is not an uncommon complication 
of a thrombosis of one of the large venous channels. The 
thrombus causes the characteristic intermittent temperature 
and masks the purulent collection situated deeply within the 
cerebral tissue. It is also common to find considerable menin- 
gitis with either cerebral abscess or thrombosis of the lateral 
sinus. This local inflammation prevents the temperature from 
intermitting, as we should expect it to do if the sinus alone 
were involved, and the fever due to meningitis may render 
the fluctuations due to the entrance of infectious material 



DIAGNOSIS. 



455 



into the circulation at frequent intervals entirely unrecog- 
nizable. 

Diagnosis. — It would seem that the recognition of the 
invasion of the osseous structures immediately surrounding 
the tympanum would be a matter of simplicity, and quite 
frequently no difficulty is experienced in making a diagnosis. 
On the other hand, we meet with cases in which even the 
most expert observer must be in doubt as to whether the 
pneumatic cells of the mastoid have become infected, or 
whether the severe constitutional symptoms are due simply 
to the conditions within the tympanum. There are two signs 
upon which the most dependence can be placed, and the pres- 
ence of both is a certain indication of mastoid involvement, 
while the presence of either one alone is certainly suspicious 
and often constitutes the sole sign upon which the necessity 
of operative treatment is based. 

These two signs are : 

i. Local tenderness upon deep pressure over the mastoid 
region. 

2. A depression or sagging of the supero-posterior wall 
of the canal close to the tympanic ring. 

In determining mastoid tenderness care must be taken to 
be sure that the pain experienced by the patient upon ma- 
nipulation is really mastoid tenderness, and does not depend 
upon an inflammation of the external canal. No error need 
occur if, when the examination is made, the examining finger 
is pressed backward and inward upon the mastoid just be- 
hind the insertion of the auricle, since this manipulation does 
not move the fibro-cartilaginous canal. On the other hand, 
if the finger of the operator causes even the slightest move- 
ment of the auricle or of the meatus, the presence of an exter- 
nal otitis may lead to error. 

The tender point is usually situated over the antrum, and 
may be close to the margin of the bony meatus ; even here it 
is not necessary to cause the slightest motion of the soft parts 
if the thumb be placed upon the margin of the bony ring 
and pressure exerted backward and inward. The tenderness 
elicited is unmistakable, the patient not infrequently cringing 
at the moment when the parts are pressed upon. It is always 
wise to test the healthy mastoid in the same manner, since a 
certain number of individuals possess what may be called a 
physiological tenderness of the mastoid process. This is 



456 INFLAMMATION OF THE MASTOID PROCESS. 

probably due to a free distribution of the sensory nerves in 
this location, and is a rather characteristic symptom in nerv- 
ous and hysterical individuals. Occasionally the region of 
the antrum may not be tender, but pain is elicited when 
the tip of the mastoid is subjected to pressure. Here we 
must be cautious not to be misled by a tenderness over the 
Eustachian tube. This is elicited if the thumb is pressed 
upon the soft parts directly behind the ramus of the jaw, and 
is almost always found in cases of severe tympanic inflamma- 
tion. To avoid this error it is only necessary to direct the 
pressure backward upon the tip of the mastoid process, avoid- 
ing- the soft parts immediately in front. Directly over the in- 
sertion of the sterno-mastoid muscle tenderness can almost 
always be elicited in healthy individuals even under normal 
conditions, and it is consequently of but little moment as a 
diagnostic sign. 

A localized tumefaction of the postero-superior canal wall 
is even more indicative of involvement of the mastoid than is 
tenderness behind the auricle. The examination of a large 
number of specimens will show that the pneumatic spaces are 
usually as richly distributed along the anterior face of the 
process — which constitutes the posterior wall of the canal — as 
beneath the external surface behind the auricle. The passage 
of communication between the vault of the tympanum and the 
mastoid antrum also lies immediately above and behind the 
inner extremity of the bony meatus, the postero-superior canal 
wall at this point forming the floor of the passage. This ex- 
plains why the sign is so important in establishing a diagnosis. 
In this condition we find the fundus of the canal much reduced 
in size, only a limited portion of the membrana tympani being 
visible, although the lumen of the meatus is normal in other 
situations. A primary external otitis is seldom met with in 
this locality, and I have never met with an instance in which, 
when this sign was present, operation upon the mastoid did 
not reveal the presence of pus. The tumor within the canal 
is extremely sensitive to pressure upon manipulation with the 
probe, and is dull and boggy to the touch. The presence of 
a large perforation in the membrana, through which secre- 
tion can be forced by auto-inflation, does not necessarily prove 
that the drainage of the mastoid process is competent. It 
will be remembered that the upper portion of the tympanic 
cavity is often completely shut off from the atrium under nor- 



DIAGNOSIS: SITE OF TUMOR. 457 

mal conditions, and when the parts adjacent are cedematous 
from inflammation complete obstruction is frequent. 

In addition to these two signs there is usually severe pain, 
especially at night ; or, if not pain, sleeplessness ; the last 
symptom is especially noticeable in chronic cases. To these 
patients the mastoid pain or headache has become a second 
nature, and a slight increase does not produce the same effect 
as the corresponding condition in a previously healthy individ- 
ual, but leads to loss of sleep. Body temperature has practical- 
ly no diagnostic value ; in acute cases we usually find an ele- 
vated temperature varying from ioo° to 102 or 103 . Where 
the middle ear has been the seat of a suppurative process for 
a long period, the mastoid subsequently becoming involved, 
it is not infrequent to find the temperature perfectly normal, 
although the temperature is taken so frequently as to pre- 
clude the possibility of any rise being overlooked. Local 
oedema behind the ear is more characteristic of a circum- 
scribed inflammation of the canal than of mastoid involve- 
ment. In young children, where the bony meatus is not de- 
veloped, tumefaction behind the ear is frequently found, and 
evacuation of the abscess may occur, although no perforation 
through the cortex is present. The fluid within the mastoid 
burrows along the postero-superior canal wall, and appears 
close behind the auricle quite early, owing to the ease with 
which it finds an exit through the Rivinian segment. In 
children, also, the cortex of the mastoid is exceedingly thin, 
and perforation may take place in twenty-four hours after 
the onset of an acute attack and produce the characteris- 
tic physical evidences. A condition which should never 
be forgotten is the occasional rupture of a mastoid abscess 
upon the internal surface through the digastric fossa. Here 
local tenderness over the antrum may be absent, the pain 
being referred to the lateral cervical region. In the early 
stages careful examination may reveal no difference between 
the corresponding regions of the sound and diseased side. 
At a later period a diffuse, brawny swelling is made out 
beneath the sterno-cleido-mastoid muscle, extending for a 
considerable distance both in front and behind it, the limits 
being poorly defined. Deep pressure over the tip of the 
mastoid elicits pain, which is frequently considered to be 
neuralgic in character, and depending upon the middle-ear 
lesion. Rupture at this point is rather characteristic of cases 
31 



458 INFLAMMATION OF THE MASTOID PROCESS. 

which have existed for a long period, and where the mastoid 
process has undergone sclerotic changes with obliteration of 
the pneumatic spaces. It is all the more necessary to recog- 
nize the condition early, since from the consolidation of the 
parts invasion of the cranial cavity is prone to occur. Occa- 
sionally necrosis of the cervical vertebrae will lead to a mis- 
take in diagnosis, but the condition is so rare that it sel- 
dom leads to error. A marked diminution in the quantity 
of the discharge, with increased pain, should always make 
one suspicious of involvement of the mastoid. In cases 
of long standing the pain may not be localized, but dif- 
fuse headache is complained of. This, together with dimi- 
nution in the discharge, is sufficiently characteristic to de- 
mand operation if other measures fail to afford immediate 
relief. 

When the intracranial structures become involved the 
manifestations already given under symptomatology will usu- 
ally be sufficiently characteristic to lead the surgeon to recog- 
nize the condition, although, as stated before, the exact loca- 
tion of the lesion may be a matter of doubt. Here local 
tenderness is of considerable value in the absence of other lo- 
calizing data. Particularly in epidural abscess the most ten- 
der point is usually over the purulent focus. 

Prognosis. — An inflammation of the mastoid is always a 
grave condition. Following an acute middle-ear affection and 
promptly treated, the prognosis is usually favorable. In very 
young children, as a sequel of an acute infectious disease, es- 
pecially scarlet fever, the advance may be so rapid as to baffle 
all our efforts to check it. In adults the condition usually re- 
sponds promptly to treatment. Following a chronic purulent 
otitis the outlook is more grave ; this is particularly true of 
cases that have been neglected and which give the history of 
several previous attacks of pain referable to the mastoid re- 
gion, which have either subsided spontaneously or have dis- 
appeared under palliative measures. Cases where the perfora- 
tion through the drum membrane is located in the membrana 
flaccida present more extensive destruction of the osseous 
structures than those in which the loss of substance is in the 
membrana vibrans. The mastoid sclerosis which is frequently 
found in such cases renders intracranial involvement more 
common. A brain abscess which has developed and remained 
latent for many years may again become active by an acute 



PROGNOSIS— TREATMENT. 459 

exacerbation of the local process within the tympanum and 
mastoid. 

Diathetic conditions such as tuberculosis and specific dis- 
ease also render the prognosis more grave. As age advances, 
the powers of resistance are diminished, and any local disease 
becomes correspondingly more serious. Diabetes seems to 
cause the parts to break down with increased rapidity, and in 
such patients not only is the local process extensive, but inter- 
current complications of an infective nature are more common. 
This should not, however, deter us from operating as early as 
the local condition demands it, since this measure affords us a 
means of cutting short the destructive process. 

With reference to the gravity of the mastoid operation it 
may be said that the procedure is in itself not dangerous. Very 
few cases are recorded in which the death of the patient can 
be traced to the operation, even although the cranial cavity 
may have been accidentally entered. An unfavorable termina- 
tion following an operation usually depends upon the extensive 
involvement found at the time, and is in no way traceable to the 
measure adopted for its relief. In four hundred and six cases 
operated on by the author, fifteen terminated fatally. One case 
died of facial erysipelas, one of acute nephritis, two of maras- 
mus, one of diabetes, and two of pneumonia. The others were 
suffering from intracranial infection before the mastoid was 
operated upon. The effect upon a previous otorrhoea is almost 
invariably favorable if a thorough operation is done, and it is 
safe to promise a cure not only of the immediate malady, but 
also of the affection which has existed so many years. 

Treatment. — When seen early, an attempt should be made 
to abort the attack; the patient must be kept quiet, and usu- 
ally confined to his bed. The diet should consist of fluids only, 
and a brisk saline cathartic be administered at once. 

If an otorrhoea is present, it must be ascertained whether 
drainage through the canal is free, and any bulging segment 
of the drum membrane should be thoroughly incised, the origi- 
nal opening being enlarged by means of a blunt knife. In ex- 
ecuting this measure it is imperative that the incision should 
be extensive, and so placed as to divide the numerous redupli- 
cations in the upper portion of the tympanic cavity. Even 
when there is no tumefaction of the anterior mastoid wall pre- 
senting in the canal, I am decidedly in favor of extending the 
section through Shrapnell's membrane outward along the supe- 



460 INFLAMMATION OF THE MASTOID PROCESS. 

rior wall of the canal for at least a quarter of an inch. After 
free drainage has been obtained, frequent irrigation with a mild 
antiseptic solution should be practiced both for cleansing pur- 
poses and to reduce the tumefaction of the parts. The applica- 
tion of cold to the mastoid is a valuable measure in the early 
stages. It is most conveniently employed by means of the Leiter 
coil, care being taken that the appliance is molded so as to 
touch the mastoid at even' point. It is not necessary to re- 
move the apparatus when the ear is to be syringed. The coil 
should be kept in position continuously for at least twelve hours, 
and better for twenty-four. At the end of this time, if local 
tenderness persists, it is probable that an operation will be neces- 
sary. Under no condition should we employ cold for a longer 
period than forty-eight hours. The internal administration of 
narcotics may be advisable during the first twenty-four hours, 
but after this time they should be withheld, as they only mask 
the symptoms. Local bloodletting was formerly much em- 
ployed, and it can not be denied that it is efficient in some 
instances. The amount to be abstracted should be considerable, 
and in the case of an adult not less than four ounces should be 
removed. The objection to the procedure lies in the local ten- 
derness which follows, which may be frequently mistaken for 
that arising from the inflammatory process. There is no objec- 
tion to its employment in connection with the use of the coil. 
As a diagnostic measure the application of cold is of value, 
since neuralgic pain is increased by the cold, while the suffer- 
ing caused by an inflammatory process is relieved by it. Tem- 
poral-}' relief almost always follows, and herein lies the danger 
of the measure being abused. Quite frequently spontaneous 
pain disappears completely after rest in bed and the employ- 
ment of cold locally for forty-eight hours. Upon examina- 
tion, the condition of the parts may not be much changed, 
the canal presenting the same tumefied, swollen condition as 
before, while pressure elicits tenderness. The abatement in 
the symptoms will persist as long as the patient is kept quiet, 
but they return when he resumes his daily vocation. This 
experience has so often fallen to my lot that I never con- 
tinue the effort to abort the attack for more than forty-eight 
hours, feeling certain if marked improvement has not occurred 
in this time that operative treatment will be necessary sub- 
sequently. 

Dr. Cunningham, my former house surgeon, presents the 



TREATMENT. 



461 



following carefully compiled statistics of the abortive treatment 
of mastoiditis: 



Natuke of Infection. 



Number of 
cases. 



Streptococcus (pure) 33 

Staphylococcus [ 3 

Pneumococcus 21 

Mixed infection, with streptococcus 

present I 25 

Mixed infection, with no streptococ- 
cus present 9 

Recovery. 

Streptococcus 

Staphylococcus 

Pneumococcus 

Mixed with streptococcus 

Mixed, no streptococcus 



Ice-coil. 


Operation. 


17 


28 


3 


2 


21 


2 


19 


23 


9 


3 



No_ 
operation. 



Ice-coil. 



Operation. 



14 per cent. 


86 per cent. 


33i 


66f " 


90+ " 


10 " 


8 


92 


66£ " 


33i 



Under " Pneumococcus " are included those cases in which 
the infecting organism was a diplococcus, resembling closely 
the " pneumococcus," but not of sufficiently definite character 
to state positively that they were the true " pneumococci." 

The value of Wilde's incision has been enormously over- 
estimated, and is only admissible in children. Here the cortex 
is so thin that the cells may be opened by firm pressure of the 
knife. In the adult, any symptom indicative of the advisability 
of this measure will become so much more marked within 
twenty-four hours that no doubt will remain as to the advisabil- 
ity of opening the mastoid cells. It is certainly unwise to subject 
the patient to two operations when one will accomplish the 
desired result. The division of the soft parts within the meatus 
over the mastoid practically meets all the indications of exter- 
nal incision, and in fact is much more efficacious, since depletion 
is more direct. The temperature scarcely calls for any special 
measures. If it is unusually high in the early stages, either 
phenacetine or acetanilicle may be given in five-grain doses, 
repeated hourly until fifteen grains have been taken. These 
drugs relieve pain, and at the same time the discomfort which 
the elevation of body temperature causes. 

General headache, especially in young children, may fre- 
quently be relieved by the application of the ice cap, and from 
the ease with which the meninges may become involved sec- 



4 62 INFLAMMATION OF THE MASTOID PROCESS. 

ondarily, the measure is of value. Failing to secure satisfactory 
relief in forty-eight hours, operative measures are imperatively 
demanded. Under no condition is it wise to delay the step 
longer than this time in chronic cases. Where the process com- 
plicates an acute middle-ear inflammation in an adult, or where 
it is primary, we would naturally hesitate about resorting to this 
measure at such an early period. Practically the question never 
arises, for in these acute cases enough relief is obtained from 
our milder measures to warrant delay. As to the particular plan 
to be followed in the operation, the weight of evidence seems 
to be decidedly in the direction of freely opening all the mastoid 
cells, so that no infected area may escape observation. The old 
method of perforating the cortex by means of the drill scarcely 
merits discussion at the present day. Recovery is always tedi- 
ous, and general sepsis a not infrequent complication, while the 
otorrhcea usually persists. 

When the entire cortex is removed and every vestige of 
softened bone taken away, while free drainage of the middle 
ear is established through the artificial opening, recovery is 
prompt and uneventful, while the aural discharge may cease 
at once, or, at most, by the time the external wound is healed. 

Schwartze * was the first to advocate a thorough exposure 
of the mastoid cells and the treatment of mastoid caries upon 
the principles of general surgery. In this country Gruening 
has advocated the removal of the entire cortex in all cases and 
has formulated the operation more exactly than any other writer. 

The operative technique is described in the section devoted 
to operative surgery. 

* Arch, fur Ohrenheilk., vol. vii, p. 157. 



CHAPTER XXVI. 
intracranial complications of tympanic inflammation. 

Otitic Meningitis. 

The meninges may be invaded in aural suppuration either 
from the middle ear itself or through the complicating involve- 
ment of the mastoid process. This invasion may occur by 
extension from caries of the osseous walls and evacuation of 
pus into the cranium, or by infection through the numerous 
vessels which perforate the internal table of the skull. In chil- 
dren it is not an uncommon complication of a suppurative 
inflammation of the middle ear. The process may affect the 
entire surface or may be localized, the favorite seat being the 
basilar meninges. 

In addition to the infection of the meninges, giving rise to 
purulent meningitis, we have, in certain cases, a train of menin- 
geal symptoms produced by an infectious process, in which an 
examination of the parts after death shows no pus to be pres- 
ent. An examination of the intracranial structures, in patients 
dying from this disease, shows one of two conditions: Either an 
effusion into the arachnoid space, with oedema of the brain sub- 
stance itself, or a dilatation of the ventricles, these cavities being- 
filled with serum. To this condition the name of " serous men- 
ingitis " has been given. The disease has been fully described 
by Quincke.* 

It must be remembered that the presence of the serous 
effusion in the ventricles or of oedema of the brain substance 
itself, is a not infrequent complication of an abscess of the brain. 
This is particularly true where the abscess lies below the ten- 
torium — that is, in the cerebellum. Here all localizing symp- 
toms may be absent, and the only symptoms from which the 
patient suffers may be due to this increased intracranial pres- 
sure, caused either by dilatation of the ventricles or by the trans- 
udation of serum into the brain substance itself. 

* Sammlung klin. Vortrage Innere Medicin, i, 29, p. 653. 

(463) 



464 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

Symptomatology. — This affection is usually accompanied 
by high temperature, which remains constant, exhibiting but 
few fluctuations, and varying from 101 to 105 . There are 
severe headache, photophobia, vomiting, and localized or gen- 
eral convulsions. In children general convulsive symptoms are 
particularly common, owing to the high temperature. In adults 
a basilar meningitis does not produce this symptom, but affects 
groups of muscles supplied by the particular nerves involved 
at their points of exit from the cranial cavity. These muscular 
contractions are succeeded by paralysis as the disease advances. 
When the basilar meninges are affected, the respiratory move- 
ments are changed in character quite early, and soon assume 
the peculiar variety known as " Cheyne-Stokes respiration," in 
which there are several short efforts at inspiration, followed by 
a period of complete cessation of the respiratory movements, 
the lungs being finally emptied by a long sighing expiratory 
effort. Delirium occurs early in young subjects, but in adult 
life the sensorium is often not involved until quite late, and 
delirium may not occur at all, the patient slowly passing into a 
condition of coma, in which state he dies. The paralyses most 
frequently met with are those caused by the involvement of the 
third, fourth, and sixth nerves. An implication of the third 
nerve causes at first contraction of the pupil, and later dilata- 
tion. One of the earliest symptoms of paralysis is failure of 
the pupil to respond to light, it remaining dilated when ex- 
posed to a brilliant source of illumination. The involvement 
of any of the nerves above mentioned will produce strabismus. 

In cases of serous meningitis, both the paralytic and con- 
vulsive symptoms are seldom well marked, and are usually en- 
tirely absent. In serous meningitis the temperature is rarely as 
high as in the purulent form; the temperature usually runs from 
102 to 103 , seldom higher. Headache is the most prominent 
symptom of this condition. This may be diffuse or localized. 
The sensorium is apt to be affected early where the meningitis 
assumes a serous form. The delirium is frequently of a mild 
type, the patient being simply restless and answering questions 
indefinitely, but after his attention is really attracted and an 
effort is made to secure an answer, the answer will usually be 
given. Where local paresis occurs, divergent strabismus is 
probably the most frequent symptom. An examination of the 
fundus oculi will most generally reveal either a choked disk or 
an incipient swelling of the optic papilla. 



DIAGNOSIS. 465 

In certain cases of middle-ear suppuration, obscure intra- 
cranial symptoms intervene which, upon autopsy, are found to 
be due to a serous meningitis. In these cases, no pus is pres- 
ent, but we have a serous infiltration, either of the meninges or 
of the brain substance, and in many cases the ventricles are 
rilled with clear serum. 

This disease was first brought to the attention of the 
medical profession by Quincke, as stated on a previous 
page. 

Diagnosis. — The recognition of the affection depends upon 
the preceding history, associated with constant high tempera- 
ture, vomiting, and headache. This group of symptoms can 
be characteristic of no other disease complicating an otitis in 
adult life. The exclusion of any acute intercurrent affection 
naturally depends upon the absence of symptoms characteris- 
tic of such a disease. In children the diagnosis is much more 
difficult, since any acute infectious disease or a disturbance of 
the gastro-intestinal canal will give rise to exactly the symptoms 
above mentioned. 

The cessation of the discharge from the ear coincident with 
the above manifestations should always render us suspicious 
of intracranial involvement, while the appearance of tonic spasm 
of individual muscles, such as those at the nape of the neck, is 
a valuable confirmatory sign. Photophobia, involvement of the 
ocular muscles, the interference with the respiratory move- 
ments, and subsequently coma, render the diagnosis unmistak- 
able in most cases. 

A sign of great value in these cases is the presence of 
choked disk. In the early stages of meningitis, examination 
of the optic disks may prove them to be perfectly normal, or 
the fundus oculi may reveal a slight congestion of the inflamed 
vessels. If, however, there are any signs of beginning choked 
disk, such as a haziness and swelling of the margin of the optic 
papilla or dilatation and tortuosity of the veins, together with 
some of the symptoms of meningitis already enumerated, the 
diagnosis is fairly certain. It is, of course, understood that the 
presence of optic neuritis is not characteristic of meningitis 
alone. This intraocular condition is frequently found whenever 
there is an intraocular lesion of any sort, which increases the 
intracranial pressure. Hence, we may have a choked disk either 
in a meningitis, a cerebral or cerebellar abscess, an epidural 
abscess, a sinus thrombosis, or in cases of intracranial tumor. 



4 66 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

Given, however, the presence of optic neuritis and symptoms 
pointing to meningitis, the presence of optic neuritis tends to 
confirm the diagnosis. As will be seen from what has gone 
before in describing the symptoms of serous meningitis, the 
diagnosis of this condition is exceedingly difficult. A menin- 
gitis can usually be assumed to be of a serous form when the 
temperature is but moderately high, not above 103 , when the 
headache is not excruciating, photophobia is absent, and where 
the symptoms develop rapidly, without the characteristic in- 
crease in temperature and increase in pulse rate. The pulse 
in serous meningitis is apt to run slow, owing to the rapid devel- 
opment of pressure symptoms. Rigidity of the neck is a quite 
frequent symptom in this form of meningitis, although it may 
be absent. 

Prognosis. — Meningeal infection is usually fatal, and yet 
the results obtained by Macewen,* who reports six recoveries 
after operation, prove that death does not always follow. In 
one case of this character, operated on by the author, f the 
operation was successful. 

Treatment. — The application of ice to the head is agree- 
able, and may retard to some extent the progress of the in- 
flammation. The administration of large closes of bromide 
of sodium or potassium is also indicated, as it lessens the irri- 
tability of the nerve centres. Opiates should be avoided, but 
may be necessary to relieve the intense pain. Free purgation 
by means of salines should be resorted to at once. The admin- 
istration of iodide of potassium internally is permissible, on the 
assumption of a possible specific taint, either hereditary or 
acquired. Surgical measures are to be employed, but to be of 
service must be resorted to early. As the disease will certainly 
prove fatal if it is not checked by operation, the surgeon should 
not hesitate to interfere even in cases which are apparently 
hopeless, if the diagnosis is unquestionable. 

Sinus Thrombosis. 

The occlusion of one of the large venous channels within 
the cranium by an infectious thrombus is always to be remem- 
bered as one of the possible complications of acute or chronic 
suppuration within the tympanum. 

* Diseases of the Brain and Spinal Cord, American edition, 1893, p. 329. 
+ Transactions, American Otological Society, 1896, vol. vi, p. 315. 



SINUS THROMBOSIS. 467 

The free communication through the mastoid veins between 
the lateral sinus and the pneumatic spaces immediately cover- 
ing it, renders a suppuration within this cavity particularly prone 
to deposit septic material within the lateral sinus. Not only 
may a suppurative process within the mastoid be complicated 
by this lesion, but a middle-ear suppuration alone, without in- 
volvement of the mastoid structures, may cause the condition as 
well. Here the channel of infection may be the superior petro- 
sal sinus or some of the smaller venous tributaries. When such 
a deposit takes place, the first step of the process is the occlu- 
sion of the sinus by a firm fibrinous clot. The development of 
pyogenic bacteria within this mass leads to general septic infec- 
tion, by the entrance of bacteria into the general circulation. 
The thrombus may remain localized within the sinus itself, 
affecting but a small area, or it may extend to the internal 
jugular vein. 

General infection may take place through the lateral sinus 
from periphlebitis, the outer cranial wall, which is deeply 
grooved for the passage of the vessel, becoming necrotic or cari- 
ous, and exciting an inflammation of the outer wall of the lateral 
sinus, lying in immediate contact with it. This is communicated 
to the interior of the vessel, causing its occlusion in the man- 
ner above described. Such a periphlebitis may lead to erosion 
of the venous trunk before its lumen is occluded by a firm 
clot, and cause a profuse haemorrhage. 

Provided life is prolonged for a sufficient period to permit 
of general infection, we find secondary purulent deposits in 
various organs of the body. The lungs seem to be the favor- 
ite site of infection, septic pneumonia being the most common 
complication. 

Secondary brain abscess is also met with, and secondary 
thrombosis of some of the other venous sinuses within the 
cranium as well. It is interesting to note that the primary 
aural affection and the primary sinus thrombosis may cause 
secondary thromboses and brain abscesses upon the opposite 
side. For this reason much uncertainty exists as to the ulti- 
mate outcome of any operative procedure directed toward the 
primary seat of affection. 

Symptomatology. — The symptoms to which this affection 
gives rise are insidious in their development, and may escape 
notice for a considerable period. The symptom characteristic 
of the involvement of one of the lanre venous channels is a 



468 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

sudden rise in temperature followed by a spontaneous fall to 
normal or nearly normal. This may be the only symptom, and, 
unless the temperature is taken at frequent intervals, may en- 
tirely escape observation. The sudden rise in temperature — 
which is usually excessive, and may reach 104 or 106 — is 
due to the passage of septic material into the general circula- 
tion at successive intervals, owing to the breaking down of the 
clot within the sinus. After this condition has continued for 
some time, symptoms of general sepsis develop, such as asthe- 
nia, emaciation, and an ashy hue of the skin. The rise in tem- 
perature is usually followed by profuse perspiration. In the 
late stages constitutional depression accompanies this, but when 
the patient is in fairly vigorous health, as at the onset of the 
disease, this depression may be so slight as to escape observa- 
tion. A severe rigor is not an unusual symptom, and is met 
with in many cases, but is quite frequently wanting. Where it 
occurs it is of great diagnostic importance, but its absence ren- 
ders the exclusion of sinus thrombosis by no means certain. 
Symptoms referable to the cranial contents — such as headache, 
local or general convulsions, paralysis, mental dullness, or de- 
lirium — are absent in uncomplicated cases. Where met with in 
connection with evidences of sinus thrombosis, we should 
always suspect the involvement of either the cerebral substance 
itself or of secondary meningitis affecting a considerable portion 
of the brain coverings. When there is a secondary process in 
some remote organ from the lodgment of infectious emboli, we 
have, in addition to the rise in temperature, symptoms peculiar 
to the organ involved. As stated above, these deposits occur 
most frequently in the lungs, and a septic pneumonia is the 
most common complication. This is of the lobular type, iso- 
lated areas of the pulmonary tissue becoming consolidated, and 
either resolving subsequently or breaking down with the for- 
mation of a pulmonary abscess. The liver and spleen may also 
be the seat of these deposits, but the symptoms presented are 
so vague as to escape recognition, and the condition is dis- 
covered at the necropsy only. 

Diagnosis. — The recognition of involvement of the lateral 
sinus is by no means difficult, as a rule. The sign most char- 
acteristic of this condition is the extensive fluctuation in tem- 
perature. In order to recognize the condition, it is necessary, 
therefore, that the temperature be taken frequently. It is wise, 
in all cases of suppurative otitis media, especially in those where 



SINUS THROMBOSIS— DIAGNOSIS. 469 

the mastoid has been involved, to have the temperature taken 
every two or three hours during the day, and at least every four 
hours during the night. If these frequent observations are not 
made, the characteristic temperature fluctuations may entirely 
escape observation, and an error in diagnosis may thus occur. 
This extensive variation in temperature is in itself sufficient to 
warrant the surgeon in assuming that the lateral sinus is in- 
volved. It should be remembered that sinus thrombosis is not 
infrequently complicated by a certain amount of meningitis. 
When this occurs, the temperature will not be intermittent, but 
remittent, the meningeal inflammation being sufficient to cause 
a constant temperature elevation of at least one or two degrees 
above the normal standard. In some cases where septic throm- 
bosis has been present for some time, the thrombus extends 
downward from the lateral sinus into the internal jugular vein. 
In these cases there is ordinarily some tenderness in the neck. 
This tenderness gradually extends downward as the disease 
advances; at first there is 'a marked tenderness just behind the 
ramus of the jaw which slowly extends down to the angle and 
then farther down the neck along the sterno-mastoid mus- 
cle. The superficial and deep lymphatics of the neck are usually 
involved quite early in the course of the disease. Some writers 
describe the presence of a hard, cord-like band, to be felt on 
palpation, along the anterior border of the sterno-mastoid mus- 
cle whenever the internal jugular is the seat of a thrombus. I 
have seen a number of cases of sinus thrombosis with extension 
to the internal jugular vein, but in no instance have I ever rec- 
ognized the presence of this cord-like band occupying the re- 
gion of the internal jugular. In my own cases, I have often 
found a brawny swelling just behind the ramus of the jaw, 
evidently caused by enlarged lymphatics. This sign is, I think, 
of some diagnostic importance in recognizing the condition 
under consideration. It must be borne in mind, however, that 
involvement of the lymphatic glands frequently occurs both in 
acute external otitis and also in otitis media, without any in- 
volvement of the internal jugular vein. Too much importance, 
therefore, should not be attached to this sign. 

An examination of the fundus oculi should always be made 
in these cases. The presence of a choked disk will confirm the 
diagnosis of sinus thrombosis in doubtful cases. 

Another symptom of diagnostic importance is the develop- 
ment of an asthenic condition without sufficient local disturb- 



4/0 



COMPLICATIONS OF TYMPANIC INFLAMMATION. 



ance, either in the middle ear or mastoid, to fully account for 
its occurrence. By exclusion this can only come from general 
sepsis, and its sudden development is indicative of the convey- 
ance of the septic material into the blood current through a 
channel of considerable size. The occurrence of rigors and 
profuse perspiration are of great diagnostic value. The exam- 
ination of the ear or of the mastoid wound, if an operation has 
been performed, furnishes practically no information of value. 

Prognosis. — A certain proportion of these cases of primary 
thrombosis recover spontaneously, although it is impossible to 
say how many die subsequently from the development of a 
cerebral abscess. The condition must, however, always be re- 
garded as grave, and one which will probably terminate fatally 
unless relieved at the hands of the surgeon. The results of 
operative treatment in these cases are exceedingly good. In 
thirty-three cases operated on by the author, twenty-eight 
were cured, and five died, from septic pneumonia, diabetes, 
septic nephritis, acute non-infectious nephritis and meningitis 
respectively. Out of the twenty-eight cases cured, in six ex- 
cision of the internal jugular was necessary. 

Where extension to the internal jugular has taken place, 
the prognosis is naturally more grave than where the disease 
is recognized before the clot has extended downward. Even 
where the jugular is involved, however, prompt operative treat- 
ment is usually efficient in saving life. Out of nine cases oper- 
ated on by the author, a cure resulted in eight. 

Pulmonary involvement is not of necessity fatal, the local 
process gradually disappearing if the powers of resistance of 
the patient are sufficient. Death usually occurs either from 
profound systemic infection, from the development of diffuse 
meningitis, from the formation of a cerebral abscess, or from 
extensive pulmonary involvement. 

Treatment. — The operative treatment proper in these cases 
will be discussed in the section devoted to surgery. This. I 
believe, should always be adopted when the diagnosis is certain. 
The only therapeutic measures to be employed are those which 
will most successfully combat the asthenic condition. The 
free administration of stimulants is indicated, alcohol probably 
being the best, as it acts both as a food and as a stimulant. 
When superficial abscesses develop, they are to be opened ac- 
cording to the general rules of surgical practice. The exhibition 
of large doses of quinine seems to be of value in diminishing 



EXTRADURAL ABSCESS. 471 

the febrile movement, thus curtailing the excessive tissue waste. 
Particular attention should be paid to the nutrition of the 
patient. The systematic administration of milk, eggs, and other 
highly nutritious and easily digested foods, should be placed 
in the hands of an experienced nurse, to aid the patient to com- 
bat successfully the infectious process. Where the stomach 
becomes intolerant, the food should be artificially digested 
before it is administered. Rectal alimentation may be neces- 
sary in some cases. 

Extradural Abscess. 

This condition is essentially one of localized purulent menin- 
gitis, in which the vis medicatrix nature? has limited the suppu- 
rative process to a smaller area of meningeal surface. In this 
condition we find the meninges adherent to the internal table 
of the skull, completely walling in the purulent collection and 
preventing the development of diffuse inflammation. Most 
commonly an abscess between the dura mater and the internal 
table of the skull is a complication of a chronic suppurative 
process within the middle ear or mastoid. The thin wall sepa- 
rating the lining membrane of the middle ear and mastoid 
process from the meninges becomes necrotic. During the 
period in which this process is taking place a localized menin- 
gitis of a low grade is developed about the affected area, so that 
when the necrotic portion separates, the corresponding dural 
area is completely shut off from the general cranial cavity. This 
evidently can not occur when the progress of the disease is 
rapid, the development of organized tissue taking place only 
after a considerable period of time. A similar localized menin- 
gitis may occur from the lodgment of an embolus or from 
thrombosis of a venous tributary, or often of one of the larger 
sinuses. For some reason the thrombus does not break down 
rapidly, but causes a subacute inflammation of the tissues in- 
closing it, so that when ulceration takes place there is no com- 
munication with the general cranial cavity. 

Symptomatology. — This condition produces few symptoms 
characteristic of its presence. The two most important signs 
are severe and continuous headache, localized over the affected 
area, a moderately elevated temperature, seldom above 101.5 ° 
or 102 , which undergoes slight fluctuations, but seldom 
reaches the normal standard. Localizing symptoms are rare. 
no portion of the motor tract being pressed upon. 



472 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

When .situated in the cerebellar fossa, vertigo and vomiting 

may occur. Mental dullness is met with in the last stages 
without reference to the location of the abscess, and is prob- 
ably dependent upon the increase in intracranial pressure from 
effusion into the ventricles. The chief diagnostic symptoms, 
however, are the temperature and the headache, which continue 
in spite of a free opening in the mastoid process. The tem- 
perature is not sufficiently elevated to indicate thrombosis or 
meningitis, this latter being also excluded on account of the 
mild character of the symptoms, while the absence of any local- 
izing manifestations and the elevation of temperature serve to 
distinguish it from an abscess in the cerebral substance. The 
headache is apt to be localized, and over the painful areas the 
parts are often exquisitely sensitive to pressure. This sharply 
localized tenderness is of importance in determining the loca- 
tion of the abscess. 

Prognosis. — A collection of pus in this situation may re- 
main latent for a long period. Any acute process involving 
the middle ear or mastoid may excite it to renewed activity, 
causing an acute diffuse meningitis or rupture of the abscess, 
with evacuation into either the cranial cavity or cerebral sub- 
stance. Death may be caused by the increased pressure if the 
rupture is intracranial, or external rupture occasionally takes 
place, with abatement of the symptoms. When the abscess is 
recognized and evacuated, recovery is the rule. Out of twenty- 
five cases operated upon by the author, twenty-three recovered 
and two died. Spontaneous evacuation through the outer wall 
of the cranium, with subsequent favorable progress, has oc- 
curred in two cases observed by Knapp. The abscesses opened 
near the occipital protuberance in both cases. 

Treatment. — Internal medication should be limited to the 
administration of supporting and stimulating agents. The only 
curative measure is the evacuation of the abscess, the technique 
of which procedure will be described later. 



Cerebral Abscess. 

A localized purulent focus within the brain tissue may be 
either acute or chronic in its development. The acute cases 
are exceedingly rare, while it is probable that the most com- 
mon cause of chronic cerebral abscess is a purulent otitis. These 
abscesses may be single or multiple; they may involve the 



CEREBRAL ABSCESS. 



473 



cortex or the deeper regions of the brain, and may be limited 
to one side, or may be met with in both cerebral hemispheres. 
They may follow either a simple inflammation within the tym- 
panum, with the formation of pus, or a similar condition within 
the mastoid, an infectious thrombosis, or an epidural purulent 
collection. The locality most frequently affected is the tem- 
poro-sphenoidal lobe, and the next in frequency is the cerebel- 
lum. Occasionally a similar process is found in the medulla, 
a rule, they are situated rather deeply in the cerebral sub- 
stance, and if left to themselves may rupture into the lateral 
ventricles. Discharge of the contents through the meninges 
occasionally occurs where the accumulation is superficial, and 
in rare instances the pus finds its way through a perforation in 
the tympanic roof, and appears externally as a discharge from 
the meatus. An abscess may remain latent for a period of 
many years, being excited to renewed activity by the occurrence 
of an acute inflammation of the region primarily involved. 

Examination of many of these abscesses shows that the 
contents are sterile, artificial cultures being entirely inert. 

Symptomatology. — If located so that pressure is exerted 
upon the motor tract or upon the motor area in the cortex, 
localizing symptoms occur. These are at first of a convulsive 
character if the process is acute, but when chronic the increase 
in pressure develops so gradually that the various areas are 
destroyed completely without any previous stage of excitation. 
Hence the paralytic stage is not preceded by one characterized 
by convulsive seizures. 

The favorite site for the development of this abscess is in 
the temporo-sphenoidal lobe, and hence characteristic local- 
izing symptoms are only produced when the abscess has at- 
tained considerable size, in which case it involves the speech 
area, and produces either sensory or motor aphasia. The apha- 
sia in these cases is sometimes only recognizable upon a rather 
careful examination. The patient may be able to answer ques- 
tions perfectly, but on being asked the names of various objects 
presented to him, will hesitate and respond slowly, or may name 
the article wrongly. This, of course, indicates involvement of 
that portion of the brain through which the fibres running from 
the visual centre to the word centre pass. In many of these 
cases, if the object presented to the patient is named, he is able 
to repeat the name; for instance, if a key is shown the patient, 
he may be unable to say the word " key," yet will repeat it after 
32 



474 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

the examiner or may say it is for unlocking the door, desig- 
nating the use of the article, but entirely forgetting its actual 
name. It goes without saying that the aphasic symptoms are 
only present where the abscess is located upon the left side. 

The symptom of agraphia is also present in some of these 
cases. As the great majority of the patients suffering from 
severe intracranial complications are met with in hospital prac- 
tice, this manifestation is not as important a diagnostic feature 
as is that of aphasia, many of these patients not being able to 
write at all or at the best writing very poorly. 

Sometimes localizing symptoms are wanting; this is 
especially true if the abscess is situated upon the right 
side, in which case the speech centres would not be in- 
volved. The asthenic condition is more indicative of the 
affection than in any special manifestation. From a rapid 
increase in the size of the abscess, local or general convulsions 
may occur; the pulse may be accelerated in acute cases, the 
relation between the pulse and the temperature being the re- 
verse of that characteristic of meningitis. In the chronic cases 
development is so insidious that the first symptom noticed is a 
condition of marked physical impairment. The mental status 
furnishes valuable information as well, the patient being irri- 
table at times, while at other times he is either inattentive 
or even somnolent. This condition of hebetude gradually 
deepens to one of coma. The temperature is seldom elevated 
above 99 ; the pulse is usually normal, occasionally intermit- 
tent. Headache of a dull, diffuse character is complained of 
in cases of long standing. Sometimes sleeplessness is the only 
symptom for which the patient seeks advice. 

The termination of the case is usually sudden, death taking 
place from rupture into the ventricles or from compression or 
destruction of the vital centres. 

Diagnosis. — In discussing mastoid inflammation, it was 
stated that the recognition of a cerebral abscess depended prin- 
cipally upon the gradual and steady impairment of the general 
health without any sufficient local cause, and, in the absence 
of symptoms, pointing to either meningitis, extra-dural abscess, 
or sinus thrombosis. 

Bergmann,* in his monograph upon the surgical treatment 
of intracranial disease, asserts that the history of otorrhoea, past 

* Hirnkrankheiten. 



CEREBRAL ABSCESS. 4 ; 5 

or present, together with persistent sleeplessness and a tempera- 
ture remaining steadily at about 99 , are sufficient indications 
for opening the cranial cavity for the purpose of exploration. 
The experience of this surgeon would certainly lend great 
weight to his statement; but in the cases which come under the 
observation of the otologist we may usually wait until some 
localizing symptoms develop or until the condition of hebetude 
is well pronounced before we interfere. The advantage of delay 
lies in the fact that more precise indications as to the particular 
location of the abscess may appear in the late stages, while the 
danger to the patient is not materially increased. 

Complicating lesions may render the diagnosis difficult, and 
it is well to bear in mind that an otitis upon one side may pro- 
duce an abscess of the opposite cerebral hemisphere, a fact which 
still further complicates our diagnosis. 

An examination of the field of vision may yield valuable 
information in locating the abscess. The ophthalmoscope may 
reveal the presence of choked disk, but this appearance is in- 
dicative of an intracranial lesion simply, and is not characteristic 
of abscess alone. 

Prognosis. — Unless surgical aid is invoked an abscess with- 
in the brain substance must cause death. It is proper, there- 
fore, to resort to surgical measures as soon as the diagnosis is 
made. In some instances it is wise to wait for the develop- 
ment of symptoms which will indicate the situation of the pu- 
rulent collection. This interval will depend much upon the 
general condition of the patient, and it is to be remembered 
that the operation is not to be delayed until the patient is too 
much exhausted to react from the operation. Of nineteen cases 
operated upon by Macewen,* eighteen recovered, while Kor- 
ner f has collated fifty-five cases operated upon, twenty-nine 
of which recovered. Of nine cases operated on by the author, 
death followed in six and three were cured. 

Treatment. — Nothing but operative interference is of the 
slightest avail in these cases. Until the surgeon is ready to 
operate, the treatment should be directed to improving the 
nutrition of the patient, so that he may be able to react from the 
operation. The technique of the operation will be considered 
in a separate section. 

* Pyogenic Infective Diseases of the Brain and Spinal Cord, Am. Ed., New York, 

1893, P. 333- 

f Die otitischen Erkrank. des Hirns, etc., 1S94, p. 145. 



476 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

Cerebellar Abscess. 

The occurrence of an abscess within the cerebellum as the 
result of purulent inflammation of the middle ear is by no means 
uncommon. 

Out of one hundred and seventy-seven cases of brain ab- 
scesses collected by Korner, ninety-eight were cerebellar and 
seventy-nine cerebral. The source of infection of the cerebel- 
lum is most frequently either through the labyrinth or directly 
through the posterior wall of the lateral sinus. Statistics show 
that the abscess is situated with about equal frequency in either 
hemisphere. Out of one hundred and three cases of cerebellar 
abscess reported by Koch,* fifty-three were in the right hemi- 
sphere, forty-eight were in the left, and in two cases both 
hemispheres were involved. 

The pathological changes which take place consist not only 
in the breaking down of the infiltrated tissue, with the formation 
of pus, but also in a collection of fluid in the lateral ventricles, 
due to pressure of the collection of pus below the tentorium. 
This pathological factor is of considerable importance, since 
the symptoms to which a cerebellar abscess may give rise may 
be entirely due to the ventricular dilatation which it causes. 

Symptomatology. — The symptoms which this condition 
produces are extremely obscure. When located deeply within 
the cerebellum, a collection of pus may cause persistent vomit- 
ing. This symptom is, however, of extremely rare occurrence, 
although uncontrollable vomiting in any case in which there is a 
history of long-continued suppuration should always be regard- 
ed with suspicion. Dizziness and unsteadiness in gait has been 
observed in certain cases. For the most part, however, the 
symptoms are those of increased intracranial pressure, no local- 
izing symptoms being present. The patient is dull, apathetic; 
sometimes, if questioned, he will complain of severe headache, 
although this is seldom a prominent symptom. In three of the 
cases which have come under my observation, the patients have 
died suddenly and undoubtedly from rupture of the abscess into 
the fourth ventricle, and the condition was discovered only upon 
autopsy. In one of these cases, persistent headache was com- 
plained of. The temperature in these cases is usually somewhat 
elevated, although it is seldom high until just before a fatal 

* Der otitische Kleinhirnabscess, Berlin, 1897. 



CEREBELLAR ABSCESS. 



477 



termination. In three cases which have recently come under 
observation, the temperature did not go above ioi° until 
twenty-four hours prior to the time of death. Two of these 
cases had a sudden and inexplainable rise of temperature, fol- 
lowed by general convulsions, coma, and death. In the third 
case the coma supervened immediately after operation. A brain 
abscess had been suspected at the time of operation, which con- 
sisted simply in the radical procedure for the relief of a long- 
standing purulent otitis. The cerebellar abscess was dis- 
covered after death. 

It will be seen from the history of these cases, and from 
many others reported in literature, that the symptoms of this 
condition are most obscure. Where such symptoms as vomit- 
ing, unsteadiness in gait or nystagmus are present in any case 
suffering with an aural discharge which has lasted for some 
weeks, the possibility of cerebellar involvement should always 
be borne in mind. 

Diagnosis. — The recognition of this condition presents 
many difficulties. I think we may say that, as a general rule, 
a cerebellar abscess will only be recognized upon the operating 
table. It may be suspected if the symptoms characteristic of 
this condition, and noted in the previous paragraph on Symp- 
tomatology, are present. As these are very frequently absent, 
however, the surgeon will probably simply make the diagnosis 
that the patient is suffering from some intracranial lesion of 
otitic origin, and the presence of the cerebellar abscess will be 
discovered upon an exploratory craniotomy. An examination 
of the fundus oculi will, in many of these cases, reveal the pres- 
ence of a choked disk. The surgeon will consider the cerebel- 
lum the probable site of the lesion, when the symptoms point to 
an intracranial collection of pus, and the localizing symptoms 
characteristic of either cerebral abscess or basilar meningitis are 
absent. It should be remembered that a cerebellar abscess not 
infrequently causes an acute dilatation of the lateral ventricles, 
and that the symptoms may be simply those of serous menin- 
gitis. Dilatation of the ventricles may be found at the time of 
the exploratory operation, and, under these conditions, it is 
always wise to explore the cerebellum, in order to find a possible 
cause for this ventricular effusion. 

Prognosis. — As the condition is so difficult of recognition, 
the prognosis is naturally unfavorable. If the disease can be 
recognized and the pus evacuated, the patient has a fairly good 



478 COMPLICATIONS OF TYMPANIC INFLAMMATION. 

chance of recovery. Macewen * reports four cases operated 
upon by himself, all of which recovered. 

Korner f reports twenty-nine recoveries out of fifty-five 
collated cases operated upon. 

Treatment. — As in the case of cerebral abscess, the only 
hope of recovery lies in operative treatment, the patient of 
course being prepared for it by nutritional and hygienic 
measures. The technique will be described later. 

* Pyogenic and Infective Diseases of the Brain and Spinal Cord, New York, 

1893, p- 333- 

f Die otitische Erkrankungen des Hirns, der Hirnhaute und der Blutleiter, p. 
191. Wiesbaden. 



SECTION III. 
SURGERY OF THE CONDUCTING APPARATUS. 



SURGERY OF 
THE CONDUCTING APPARATUS. 



Under this section we shall consider those procedures de- 
manded by various pathological conditions affecting this por- 
tion of the body. While the term embraces all operations 
upon the auricle, canal, tympanum, mastoid, and adjacent re- 
gions, it is evident that many of these belong more to the do- 
main of general than of special surgery. In this section we 
shall confine ourselves to those operations which are not con- 
sidered in detail in works on general surgery and which are 
of interest to those engaged in special work. 

For this reason operations for the removal of neoplasms of 
the auricle or for the correction of deformities of the external 
ear will not be described. On the other hand, the frequent 
occurrence of intracranial complications as the result of aural 
suppuration renders the consideration of the proper treat- 
ment of such affections imperative. 



CHAPTER XXVII. 

middle-ear operations. 

Preparations Preliminary to Operations upon the 
Tympanic Cavity. 

Instruments. — Every operator will from habit develop a 
preference for some particular form of instrument which in 
his hands will be more valuable than one of another pattern. 
Emphasis should be laid upon the fact that in this branch of 
surgery, as in all its branches, the object to be attained should 
be kept in mind rather than the particular appliance with 
which it is to be effected. In a general way the operator 

(481) 



482 



MIDDLE-EAR OPERATIONS. 



should have at hand delicate, sharp and probe-pointed knives, 
of both the curved and the straight variety ; a number of an- 
gular knives, the blade in each knife being bent close to the 
point, either to an obtuse or right angle, according to the par- 
ticular use for which it is intended ; several blunt and sharp 
hooks, varying in size and curve ; curettes ; sharp spoons, both 
straight and angular ; delicate forceps for removing detached 
portions of tissue, and an ecraseur for the same purpose. In 



f 



f \ 



be J e f g h 

Fig. 123. — Instruments for middle-ear operations 



1 J 



addition to these, the ordinary speculum used in examination 
will be necessary, together with a large number of cotton hold- 
ers for cleansing the parts during the course of the operation, 
and probes, both stiff and flexible, for tactile exploration. It 
has been a matter of much discussion as to the advisability of 
using a straight knife or one in which the handle makes an ob- 
tuse angle with the shaft in operations of this character. The 
question should be decided by individual experiment. For 



PREPARATION OF THE EAR. 483 

a number of years I have employed with great success a series 
of instruments the blades of which are forged from small steel 
wire of the correct size (Fig. 123). The shaft of each instru- 
ment is provided with a screw thread which enables it to be 
fastened firmly into a small handle made of octagonal brass 
rod. The shank of the knife is left malleable, which permits 
of its being bent at an angle with the handle, or being used as 
a straight instrument, according to circumstances. These 
instruments are comparatively cheap, and this is a matter of 
considerable consequence, as the instruments become useless 
after a few operations. It is important that all knives should 
possess sufficient thickness at the back to permit the blades 
to be honed to a keen edge. No cutting instrument which is 
thin and spatula-like can be brought to a fine edge, no matter 
how much care is exercised. Too much stress can not be laid 
upon the necessity of having all cutting instruments as sharp 
as care and art can make them. It may seem superfluous to 
lay much stress upon this point, but it is so commonly neg- 
lected in aural surgery that I feel warranted in emphasizing 
it here. 

Concerning the preparation of the instruments for opera- 
tion, immersion in a boiling soda solution of the strength of 
one per cent has in all cases proved satisfactory. The larger 
instruments, such as forceps, probes, specula, etc., may be al- 
lowed to remain in the boiling solution for from three to five 
minutes. Delicate knives, however, should be simply im- 
mersed for a moment and then withdrawn. 

Preparation of the Field of Operation. — Where there has 
been no discharge from the external auditory meatus it usu- 
ally suffices to cleanse thoroughly the ear at the time of the 
operation by means of a solution of bichloride of mercury of 
the strength of 1 to 3,000 in equal parts of alcohol and water, 
the lotion being applied by means of a cotton-tipped probe. 
The walls of the canal should be thoroughly scrubbed so as 
to remove not only any superficial deposit which may be pres- 
ent, but also any desquamated epithelium which may adhere 
closely. It is better, however, to precede this cleansing bv 
having the ear syringed once daily upon the two days preced- 
ing the operation with an aqueous solution of the bichloride 
of mercury of the strength of 1 to 5,000, the canal being oc- 
cluded by a pledget of sterilized cotton immediately after the 
irrigation and the pledget allowed to remain in situ until the 



484 MIDDLE-EAR OPERATIONS. 

next cleansing. It is a fact not ordinarily recognized that 
low vegetable organisms, such as various forms of aspergillus, 
are encountered quite frequently in the external auditory 
meatus, and in no small degree tend to excite inflammatory 
action after operative procedures ; and it is for the purpose 
of thoroughly eradicating these growths from the field of 
operation that the above measures are advised, even in cases 
where the canal seems perfectly clean. Where there has been 
an otorrhcea of long standing it is still more necessary to 
cleanse the parts thoroughly by irrigation with antiseptic lo- 
tions before resorting to any operation. Thorough syringing, 
either once or several times daily, according to the amount of 
discharge, is imperative for at least five days before any op- 
erative procedures are attempted. The particular antiseptic 
chosen is a matter of little importance ; the bichloride-of-mer- 
cury solution of the strength of 1 to 5,000, or a dilute solution 
of peroxide of hydrogen, or of carbolic acid 1 to 50, or a satu- 
rated solution of boric acid, are all fairly efficient. Either a 
few hours before the operation or immediately preceding it 
the field should be cleansed with the alcoholic solution in the 
manner mentioned before. 

Where proper attention has not been paid to cleanliness, 
we frequently find in old cases of otorrhcea that the tympa- 
num is filled with exuberant granulations due to the effect of 
heat and moisture, as well as to the presence of necrosed bone. 
Cleansing will do much to reduce these efflorescent masses, 
but it may be necessary to curette thoroughly the entire cav- 
ity before any further operative measure is employed, in order 
that the extreme vascularity of the parts may not interfere 
with a delicate operation in such a limited field. Where evul- 
sion is not indicated the actual or chemical cautery may re- 
duce the granulations sufficiently. 

Anaesthesia. — Where the membrana tympani is present it is usually pos- 
sible to perform the various operations upon the middle ear under local anaes- 
thesia, provided the patient possesses a fair amount of self-control. When 
the membrana tympani is to be incised for the relief of an acute inflammatory 
process of the middle ear, the procedure is rendered entirely painless by ni- 
trous oxide anaesthesia. In operations having for their object an improve- 
ment of the hearing it is particularly advantageous that the patient shall re- 
tain consciousness throughout, in order that the results of the various steps 
may be closely noted. The primary incision through the membrane is the 
only step attended with pain, and this is insignificant where the knife is in a 
proper condition. Absolute anaesthesia is obtained subsequently by touching 



CLASSIFICATION OF OPERATIONS. 485 

the edges of the incision with a cotton-tipped probe moistened with a ten-per- 
cent solution of cocaine, the probe being subsequently introduced into the 
tympanic cavity to anaesthetize its lining membrane. As the local application 
of cocaine to the middle ear may be followed by unpleasant constitutional 
effects in certain cases, it is often wise to use first cocaine, and then a two- 
per-cent solution of eucaine (B). The only disadvantage of the latter drug is 
that it causes considerable hyperemia. The anaesthesia, however, is of longer 
duration than that produced by cocaine. Quite recently it has been discov- 
ered that an aqueous extract of the desiccated suprarenal capsules of the 
sheep possesses decided haemostatic properties. Such a solution, properly 
sterilized, is of great advantage in middle ear operations, as it practically con- 
trols the haemorrhage, and enables the surgeon to obtain an unobstructed 
view of the field of operation. 

The Position of the Patient. — Since we are accustomed to inspect the 
ear with the patient either in an erect or semi-recumbent posture, it is some- 




Ftg. 124. — Author's head and shoulder rest. 

what inconvenient to operate with the subject in the horizontal position. If a 
general anaesthetic is necessary the upright position is not available, but here 
it is always advisable to operate with the shoulders elevated so that the head 
can easily be turned in any direction, The rest shown in Fig. 124 will be 
found convenient in securing this end if a suitable operating chair or table is not 
at hand. 

Classification of Operations. 

The various intratympanic operations may be classified as 
follows : 

I. Operations involving the Membrana Tympani alone, com- 
prising-, (a) Perforation of the membrane (myringotomy), {b) 
Removal or destruction of a segment of the membrane to 
establish a permanent opening (partial myringectomv). (c) 
Single or multiple incision of the membrana tympani to cor- 
rect anomalies of tension. (We include here section of the 
posterior fold, or plicotomy.) 

II. Operations involving the Intratympanic Soft Parts. — (a) 
Tenotomy of the tensor tympani muscle. (&) Section of 



486 



MIDDLE-EAR OPERATIONS. 



the anterior ligament of the malleus, (c) Section of adhesions 
resulting from suppurative or nonsuppurative inflammation. 

III. Operations involving the Ossicular Chain. — (a) Excision 
of a portion of the malleus, (b) Disarticulation at the incudo- 
stapedial joint, or division of the long arm of the incus, with 
mobilization of the stapes, (e) Plastic operations for uniting 
either the stapes or the incus to the membrana tympani 
directly, (d) Excision of individual ossicles, or of the entire 
ossicular chain. 

I. Operations involving the Membrana Tympani alone. 

(a) Myringotomy. — A simple incision through the drum 
membrane may be performed either to evacuate fluid, to 
deplete the parts, or for the purpose of exploration. Former- 
ly the drum membrane was considered 
so important a structure that interfer- 
ence with it was seldom deemed justi- 
fiable. Too much can not be said for 
the purpose of correcting this error. 
Granting that the instruments, the field 
of operation, and the operator are asep- 
tic, an extensive incision through the 
structure, even in a state of health, will be 
followed by no untoward consequences. 
The linear wound will heal completely 
within twenty-four hours and the func- 
tion of the organ will in no way be in- 
terfered with. For whatever purpose 
the procedure is employed, it should al- 
ways be remembered that the incision 
should be free rather than limited in ex- 
tent. Formerly, for the evacuation of 
fluid within the tympanum it was the 
custom to " puncture " the drum mem- 
brane with a small lance-shaped knife 
(Fig. 125). The failure to secure speedy 
convalescence was then attributed to the operation. At the 
present day, when we wish to evacuate fluid from the tym- 
panum, the parts are freely incised and the cavity emptied, 
and at the same time the vascular turgescence is relieved, 
so that the cut edges approximate closely and unite at the 
end of a few hours. 




Fig. 125. — Myringotome. 



MYRINGOTOMY. 487 

Operation. — The field of operation and the instruments 
being thoroughly aseptic, the surgeon exposes the fundus of 
the canal by the insertion of a speculum of the proper size. 
The site of election for perforating the drum membrane varies 
according to the manifestations in each particular case. If 
fluid is to be evacuated our incision should commence at the 
most prominent point and should extend either upward or 
downward through the bulging portion. Section is most 
effective by using the sharp knife shown in Fig. 123, e. If the 
bulging involves chiefly the upper part of the drum mem- 
brane the knife should be carried into the canal with the cut- 
ting edge upward. Its point is entered at the apex of the 
tumefaction and carried rapidly through the drum until it im- 
pinges upon the internal tympanic wall, after which it is made 
to cut upward toward the periphery as far as may seem neces- 
sary (Fig. 97). As the most prominent region is almost in- 
variably in the posterior quadrant, and usually in the postero- 
superior, care must be taken to avoid striking the long por- 
tion of the incus with the point of the knife. When the pri- 
mary incision is made the malleus shaft can usually be suffi- 
ciently well made out to be avoided ; but if the knife impinges 
upon this the operator will have failed to secure a proper 
opening, the resistance being firm and the knife seldom glid- 
ing off so as to pass through the membrane and evacuate the 
contents of the cavity. To avoid injuring the incus and stapes 
it is necessary that the operator should hold the instrument 
delicately between the thumb and finger in making the up- 
ward stroke, when contact with these structures will be im- 
mediately recognized, and the blade may be slightly turned 
so as to avoid them. Where the most prominent area corre- 
sponds to the low T er half of the tympanic cavity incision in the 
opposite direction is usually more convenient. In this case the 
knife is introduced in the canal with the cutting edge down- 
ward. Here no important structures can be encountered and 
the procedure is relatively simple. It is usually wise to make 
this incision somewhat curvilinear, following the peripheral 
attachment of the membrane, the incision passing close to the 
cartilaginous ring. Approximation is more perfect when the 
wound is located here and cicatrization correspondinglv more 
rapid. In all cases attended with congestion or an inflamma- 
tory process the inner tympanic wall should be incised at the 
same time to secure local depletion. Regarding the absolute 



488 



MIDDLE-EAR OPERATIONS. 



extent of the incision, it is seldom wise that this should be 
shorter than one fourth of the long diameter of the membrane 
if lying in a vertical direction, or less than one eighth of the 
periphery if located near this. 

It is well to remember that the plane of the membrana 
tympani is obliquely placed to both the horizontal and vertical 
transverse planes of the body. An instrument introduced 
into the meatus and carried horizontally inward will frequent- 
ly not pass through the drum membrane, but will be de- 
flected from its surface and inflict but a superficial wound. 
This is particularly true when the bulging involves the supe- 
rior segment, and in children. In order to enter the tym- 
panic cavity the knife must be passed not only inward, but 
inward and upward, and even after the point has passed 
through the membrane the handle should be strongly de- 
pressed, so as to carry the blade well up into the cavity. In 
an infant the plane of the membrane is nearly horizontal, and 
unless particular attention is given to this fact the operation 
will be inefficiently performed. It is well in operating upon 
a young child, and even upon an adult where the canal is nar- 
row, to employ a curved knife (Fig. 87) rather than a straight 

one, as an extensive incision is 
more easily made if this is done. 
Where myringotomy is per- 
formed for depletion alone in 
those cases where the acute in- 
flammatory process has begun 
in the vault of the tympanum, 
the atrium remaining free, our 
success in aborting the attack 
will depend largely upon the 
thoroughness with which we 
divide the connective -tissue 
structures lying in the tym- 
panic vault. In such a case the 
knife should be introduced with 
the blade lying in the horizon- 
tal plane, the cutting edge look- 
ing backward (Fig. 126). The 
point punctures the drum membrane just above and behind the 
short process of the malleus, the knife being passed upward 
and inward and a little backward, to avoid the body of the 




Fig. 126.— Incision of Shrapnell's mem- 
brane in the early stages of acute 
purulent otitis. (The continuation 
of the incision upon the superior 
wail of the canal is indicated by the 
dotted line.) 



EXPLORATORY MYRINGOTOMY. 



incus. The incision is then carried horizontally backward to 
the periphery, when the cutting edge of the knife is turned 
upward and the incision extended for a short distance along 
the superior wall of the canal (as shown by the dotted line in 
Fig. 126). This severs the numerous reduplications of mucous 
membrane and efficiently depletes this region and the lining 
membrane of the mastoid antrum. 

Exploratory Myringotomy. — When it seems desirable to 
explore the interior of the tympanum, the end is most easily 
attained by reflecting a flap of 
the membrana tympani. As the 
region demanding particular in- 
spection is that occupied by the 
incudo-stapedial articulation and 
the niches of the oval and round 
windows, the field of operation 
lies in the posterior segment. 
This has been proved to be the 
part possessing the least tactile 
sensibility, and primary incision, 
if located just within the clear 
membrane close to its posterior 
border and midway along the 
periphery, can be made with 
scarcely any pain. The knife 

should possess so keen an edge and so sharp a point that it 
will penetrate the delicate septum by its own weight. The 
puncture should be made within the clear membrane to 
avoid haemorrhage, and especial care is to be taken that 
the mucous membrane over the internal wall is not wounded, 
for the same reason. After a short incision has been made 
in this region a ten-per-cent solution of cocaine is applied to 
its margins by means of a cotton-tipped probe, after which 
the section is carried upward along the peripheral attach- 
ment to the posterior fold, then forward just below this to the 
short process of the malleus, where it again turns downward 
and runs parallel with the manubrium and posterior to it (Fig. 
127). It is usually necessary to repeat the process of anaes- 
thetizing several times before the incision is completed, but if 
this is carefully done not the slightest pain is experienced. 
The flap now falls outward and the tympanic cavity lies open 
to inspection (Fig. 136). In the great majority of cases the in- 

33 




Fig. 127. — Exploratory myringotomy. 



490 MIDDLE-EAR OPERATIONS. 

cudo-stapedial articulation will readily be seen, and the de- 
gree of mobility of the stapes and the amount of motion pos- 
sible at the malleo-incudal joint can be determined by manip- 
ulation with a cotton-tipped probe or by passing a delicate 
hook behind the descending arm of the incus. If the round 
window is not exposed, or if the flap does not turn readily, 
the original incision may be extended downward along the 
posterior peripheral margin as far as the inferior pole. Dis- 
placement of the flap may not expose the incudo-stapedial ar- 
ticulation and the niche of the round window in some cases, 
as these may be covered by the fold of the posterior pocket 
or by certain irregular reduplications of the mucous mem- 
brane. These folds may be so delicate that they are recog- 
nized with difficulty and yet hide completely the landmarks 
within the tympanum. If the various landmarks are not seen 
upon reflection of the flap, the sharp-pointed knife should be 
used to make one or two short vertical incisions through the 
membrane over the inner tympanic wall. The edges of the 
incisions separate, from the elasticity of the membrane, and 
the landmarks appear. The cavity having been explored and 
the indicated measures adopted, the flap may be replaced and 
held in position by a bit of thin sized paper which has been 
previously soaked in a solution of bichloride of mercury (i to 
3,000). This paper dressing is introduced into the meatus 
either on the end of a cotton-tipped probe or by means of a 
forceps, and is placed upon the surface of the drum mem- 
brane, and by manipulation made to slide over this until the 
flap is replaced, when further manipulation carries the paper 
disc over the line of incision, sealing it and retaining the 
edges in position by its adhesion to the surrounding intact 
surface. At the end of one or two days the healing process 
is complete, and the paper is subsequently thrown out by 
the outward growth of the epithelial layer of the membrana 
tympani. 

(b) Partial My ringed omy. — It is seldom possible, by the ex- 
cision of any portion of the membrana tympani or by destruc- 
tion by caustic agents, to secure a permanent opening through 
the drum membrane. When we desire to determine what 
the effect of a permanent opening would be in any given case, 
a partial myringectomy will enable us to attain this end, al- 
though the opening will usually close at some subsequent 
period. 



MULTIPLE INCISION OF THE MEMBRANA. 4gi 

The operative technique consists in the excision of a flap 
which is to be formed in the manner already described in ex- 
ploratory myringotomy. If caustic agents are to be used, a 
minute drop of the concentrated sulphuric acid is applied, by 
means of a cotton-tipped probe, to the area chosen for per- 
foration, care being taken that no acid in excess of what is re- 
quired to saturate the cotton, is conveyed into the canal. The 
instrument is carried rapidly through the canal and pressed 
against the membrane for a few seconds, causing a rapid ne- 
crosis of all the layers, the affected portion becoming of a dead- 
white color. The probe easily breaks down this necrotic tis- 
sue and enters the tympanic cavity. There is but slight pain, 
and if care is taken to use but little acid there is seldom any 
reaction. The galvano-cautery may be employed in the same 
manner. Comparing these three methods, excision is un- 
doubtedly the safest plan, but it is the most difficult to ac- 
complish, the removal of the small flap being by no means 
easy. The small scissors shown in Fig. 128 will be found 




Fig. 128. — Author's scissors for middle-ear operations 



useful in separating the flap when it is attached by a narrow 
pedicle only. When the flap can not be excised, it may be 
folded upon the outer surface of the membrane, the pedicle 
by which it is attached being made as narrow as possible. 
Unless the flap is replaced, the opening will remain patent for 
from two to six weeks, during which time the conditions are 
much more favorable for observation than where resort has 
been had to undue violence completely to excise the flap, 
or where the parts have been irritated by either an escharotic 
or the actual cautery. 

(c) Multiple Incision of the Membrana Tympani. — Politzer * 
and Gruberf both propose this operation, but for exactly 
opposite conditions, the former advising it where the mem. 
brana is much relaxed as the result of the cicatrization of a 
larger perforation, while the latter employs it to relieve in- 



Wien. med. Woch., 1S71, p. 9. f Allg. Wien. med. Ztg., 1S73, 



492 



MIDDLE-EAR OPERATIONS. 



creased tension, the result of an inflammatory process. Gru- 
ber advises that several incisions be made from the centre of 
the membrane toward the periphery, through the dense areas, 
the adjacent incisions being connected by tranverse cuts, the 
lines of section forming the letter H. Where it seems advisa- 
ble to employ the procedure for a relaxed condition, it is neces- 
sary only to divide the cicatrix completely, or in some cases 
to excise a portion of it. It would be exceptional to find any 
permanent benefit from this operation, since the newly formed 
cicatrix must soon become relaxed. 

Plicotomy. — The posterior fold of the membrana tympani 
may be divided for the relaxation of tension, either in the 
direction of or at right angles to its long axis. When it is to 
be divided transversely the point of the knife is entered just 
above the posterior fold, midway between its posterior ex- 
tremity and the short process of the malleus. After piercing 
the membrane a quick downward stroke severs the tense band. 
In order that immediate reunion shall not take place Politzer- 
ization or inflation by means of the catheter should be prac- 
ticed daily for four or five days. 

The longitudinal section of the fold needs no special de- 
scription. The knife punctures the membrane just below the 
fold near the anterior or posterior end and divides horizon- 
tally the tissues immediately below the band. It thus severs 
any radiating fibres and relaxes the tension. 

II. Operations in which the Various Muscular or 
Fibrous Structures within the Tympanum are 
divided. 

(a) Tenotomy of the Tensor Tympani Muscle. — This proce- 
dure was proposed by Hyrtl,* although F. E. Weber \ was 
the first to perform it upon the living subject. The indica- 
tions for its performance have been sufficiently stated in an 
earlier portion of the volume. 

Since in a sclerotic condition of the mucous membrane of 
the middle ear tactile sensibility is much diminished, it is 
usually stated that general anaesthesia has seldom been neces- 
sary for the performance of the operation. My own experi- 
ence has been, however, that it is less readily carried out than 
some of the more complicated procedures within the tym- 

* Topographische Anatomic f Berlin, klin. Woch.. 1871, p. 574. 



TENOTOMY OF THE TENSOR TYMPANI. 



493 



panic cavity, and I believe that in order to be successfully per- 
formed general anaesthesia should be induced in most cases. 

There are several methods of severing the band. Weber- 
Liel, and Cholewa make use of a knife of special construction 
for dividing the tendon. In this instrument the blade is hook- 
shaped and the shaft of the knife is fixed in an angular handle 
so arranged that the knife can be rotated upon its long axis 
by the manipulation of a slide on the side of the handle. The 
technique is as follows : The membrana tympani is incised in 
front of the processus brevis, the hook-shaped knife introduced 
into the cavity, and by depressing the handle and carrying it 
somewhat forward the blade is made to press upon and par- 
tially encircle the tendon ; by rotating the blade 
the tendon is severed. To remove the knife the 
blade is rotated to its former position by revers- 
ing the manipulation. Forcible inflation by Po- 
litzer's method or with the catheter, and the 
insufflation of a little boric acid into the canal, 
completes the operation. Most commonly the 
procedure is conducted without resort to so 
complicated an instrument as the one described, 
and most operators prefer to enter the tympanic 
cavity behind the malleus handle. Gruber* ad- 
vises that the tenotome be introduced through 
the membrane in either the anterior or poste- 
rior segment, according to their relative acces- 
sibility. Schwartze, Pomeroy, and Green em- 
ploy a blunt-pointed knife curved on the flat. 
Hartmann has devised an instrument (Fig. 129) 
which is curved both on the flat and in its long 
axis, the blade being sharp-pointed, so that 
when the middle ear is entered the sharp point 
of the knife can be carried high up into the 
tympanic cavity The position of the puncture 
and the manipulation of the instrument after 
the blade has entered the tympanic cavity will 
vary according as the tendon is to be divided 
from above downward or from below upward, 
the operator is allowed considerable latitude. The technique 
depends upon the conformation in each individual case. If 



ry 



Fig. 129. — Hart- 
mann 's teno- 
tome (slightly 
enlarged). 

Here atrain 



* Lehrbuch fiir Ohrenheilkunde, Wien, iSSS, p. 562. 



494 



MIDDLE-EAR OPERATIONS. 




Fig. 130. — Tenotomy of the tensor tympani. 
The knife is shown above the tendon, which 
is divided from above downward. 



the tendon is to be divided from above downward the mem- 
brane is punctured immediately behind the short process, 
and the curved or angular blade is carried high up into the 

cavity by depressing the 
proximal end of the in- 
strument, which at the 
same time is carried a 
little backward, causing 
the blade to apply itself 
closely to the manubrium. 
The blade is then rotated 
forward and downward 
through an angle of nine- 
ty degrees, and section is 
accomplished by a slight 
sawing motion, down- 
ward pressure being ex- 
erted during the with- 
drawal of the instrument. 
As the tendon is severed 
the operator feels the resistance which it offered suddenly 
overcome, and a sharp click is frequently heard at this mo- 
ment. To divide the tendon from below upward the mem- 
brana is punctured just 
below and behind the 
short process. Upon en- 
tering the cavity the in- 
strument is advanced for- 
ward, inward, and down- 
ward, the shaft remaining 
almost horizontal, and 
the flat surface of the 
blade closely applied to 
the handle of the malleus 
until it has traversed the 
breadth of the cavity. 
The handle is then de- 
pressed, thus carrying 
the curved point of the knife high up in the tympanum. 
The instrument is then withdrawn, upward pressure being 
continually exerted and the tendon divided from below up- 
ward. The technique described presupposes the use of 




Fig. 131.- 



■Tenotomy of tensor tympani with 
Hartmann's knife. 



DIVISION OP THE ANTERIOR LIGAMENT. 



495 



Hartmann's tenotome, which, being sharp-pointed, is used 
both to puncture the membrane and to sever the tendon 
{Fig. 131.) When a blunt-pointed knife curved on the flat is 
used, the drum membrane is incised close to and behind the 
handle of the malleus with a sharp knife ; through this open- 
ing the curved knife is inserted, its concavity being directed 
toward the manubrium. The tendon is divided by depress- 
ing the handle of the knife and extending the incision upward 
toward the short process (Fig. 132.) When it seems desir- 
able to divide the tendon 
through an incision in 
the anterior segment, 
the curved knife enters 
the cavity somewhat be- 
low the short process. It 
is then advanced upward 
and backward, the flat 
surface of the blade pass- 
ing closely along the 
manubrium and severing 
the tendon as the incis- 
ion is extended. Where 
tenotomy is deemed ad- 
visable in cases of resid- 
ual purulent inflamma- 
tion, a large perforation being present, no preliminary in- 
cision is necessary, the knife being introduced through the 
existing perforation ; the tendon is severed either from below 
upward, or in the reverse direction, according to the special 
topography of the case. 

(b) Division of the Anterior Ligament of the Malleus. — This 
measure was advocated by Politzer** in cases of marked re- 
traction of the membrana tympani, it being found in several 
instances that tenotomy of the tensor tympani alone did not 
allow the parts to resume their normal position, although this 
was possible if the anterior ligament had been severed. 

The membrane is punctured just in front of the short pro- 
cess with a short curved knife, with the cutting edge directed 
upward. The knife is carried inward almost to the bonv wall, 
when the handle is depressed, crowding the edge against the 




Fig. 132. — Tenotomy of tensor tympani from 
below upward. 



Diseases of the Ear, Am. edition, Philadelphia, 1SS3, p. 379. 



496 MIDDLE-EAR OPERATIONS. 

ligamentous tissue in the anterior fold, which is divided as the 
knife is withdrawn. 

(c) The Division of Adhesions, the Result of Suppurative or 
Nonsuppurative Inflammation. — We may divide these adhesions 
according to their location into two classes : 

1. Adhesions about the stapes itself. 

2. Adhesions between the malleus and incus and inner- 
tympanic wall, or tense bands immobilizing the entire ossicular 
chain, the articulations between the various ossicles being 
intact. 

When the rigidity depends upon adhesions about the 
stapes itself as the result of a purulent otitis, the incudo-sta- 
pedial articulation having been destroyed, we find the pelvis 
ovalis occupied by a mass of dense tissue which frequently 
changes the appearance completely. The head of the stapes 
may present only as a slight elevation upon the surface of the 
mass. Close inspection may reveal a preponderance of the 
newly formed tissue along the posterior margin of the pelvis, 
especially about the stapedius tendon, which can occasionally 
be seen as a bright line running through the mass. To see 
the stapes or what remains of it I usually first incise directly 
downward close to the tympanic ring, so as to divide any 
bands which may tend to pull the stapes out of the visual field. 
To effect this the knife is to be carried inward just above the 
fibrous band which we wish to divide, and close to the tym- 
panic ring, until its point impinges upon the bony inner wall 
of the tympanum (Fig. 134.) It is then carried downward, the 
point being still kept against the inner wall, and severs the 
tendon of the stapedius, together with all adhesions which 
passed from the ossicle toward the posterior tympanic wall. 
This relieves the stapes from the pull of the stapedius muscle, 
and from the tension of the adhesions which have developed in 
front, it comes more clearly into view. Care should be taken 
in passing the knife inward not to carry it too far, in case the 
bony resistance is not felt at the proper depth, for fear of its 
entering the vestibule and injuring the labyrinth. After the 
posterior bands have been severed, short radiating incisions, 
are made, taking the oval window as a centre from which they 
diverge. This allows the parts to retract, and by local de- 
pletion favors the formation of a thin cicatrix, in place of the 
thick fibrous deposit. The operation is completed by the in- 
sufflation of a little boric acid. It may be necessary to repeat 



DIVISION OF ADHESIONS. 



497 



this procedure several times before the desired result is ob- 
tained, since during cicatrization other adhesions may form. 
Careful attention will enable the surgeon to overcome the 
rigidity permanently in a large number of cases. 

In the second class of cases, where the entire conducting 
chain is bound down, relaxation of tension is frequently ob- 
tainable by surgical interference. In many cases a large per- 
foration is found, in the lower half of the membrane, the mar- 
gins of the perforation may adhere to the internal wall of the 
middle ear throughout ; or this condition may be confined to 
the region of the tip of the malleus handle. In these last 
cases the blunt knife, curved on the flat, should be used to 
divide the fibrous bands, or in some cases vertical incisions 
may be made through the cicatrix, or the point of adhesion 
may be taken as a centre from which these incisions shall 
radiate. 

Another condition, not uncommon, is where a consider- 
able portion of the membrane is destroyed, the remnant of 
the membrane in the upper 
and posterior quadrant be- 
ing thickened and tense, so 
that its lower border, cor- 
responding to the posterior 
fold, forms a dense fibrous 
band, crowding the under- 
lying structures firmly to- 
gether, and sometimes par- 
tially hiding the stapes or 
incudo-stapedial articulation 
from view. Section of this 
band, by an upward incision 
(Fig. 133), frequently im- 
proves the hearing ; or the 
procedure may be advisable 
as an exploratory measure, 

the retraction of the cut edges permitting an inspection of 
the structures lying in the pelvis ovalis, and revealing a con- 
dition here which may be amenable to operative treatment. 

Adhesions following a nonsuppurative inflammation will 
usually be less amenable to operative treatment than those 
developing in the residual purulent cases. The reason for 
this is that in the nonsuppurative cases the constricting bands 




Fig. 133. — Incision of cicatricial band to 
expose the incudo-stapedial articulation 
or to free the stapes. 



49 8 MIDDLE-EAR OPERATIONS. 

are seldom confined to any one locality, but involve the entire 
ossicular chain and the pelvis ovalis as well. The condition 
is one demanding extensive and sometimes repeated operative 
measures, and the best results are obtainable by first remov- 
ing the membrana tympani and the two larger ossicles. This 
procedure permits a thorough inspection of the pelvis ovalis 
and of the stapes, and enables the operator to resort to re- 
peated surgical procedures or mechanical measures for the 
relief of tension existing in this locality, while the primary 
operation eliminates anomalies in tension arising from other 
causes. 

III. Operations involving the Ossicular Chain. 

(a) Excision of a Portion of the Manubrium Mallei and of a 
Large Part of the Membrana was proposed by Wreden * in cases 
where it was deemed advisable to secure a permanent opening 
into the tympanum. The procedure has fallen into disuse, 
since it does not accomplish the desired end. The technique 
needs no special description, consisting merely of making a 
circular incision of the desired size by means of a sharp knife, 
the umbo being taken as the centre. After the section has 
been completed, the fibrous lamella which it encloses will be 
held by the manubrium alone, and may be removed by cutting 
through the malleus handle by means of an ecraseur, cutting 
forceps, or other appropriate appliance. 

(b) Disarticulation at the Incudo-st ape dial Joint, or Division of 
the Long Ar m of the Incus and Mobilization of the Stapes. — This 
procedure is of especial value in the residual purulent cases 
where the articulation is exposed, or is covered by a thin 
cicatrix only, through which it is easily visible. It is of less 
value in chronic nonsuppurative inflammation, since the open- 
ing which is made through the membrane to expose the parts 
soon closes, rendering it almost impossible for the surgeon to 
relieve by secondary operation any unfavorable results attend- 
ing cicatrization. Where the long arm of the incus and the 
posterior crus of the stapes are exposed, disarticulation is 
effected by means of the angular knife shown in Fig. 123,/ 
and g, which is inserted behind the descending process of 
the incus, and made to pass through the articulation by cut- 
ting downward. Any portion of the capsule undivided may 

* Monatsschrift fur Ohrenheilkunde, vol. i, p. 22. 



DISARTICULATION AND MOBILIZATION OF THE STAPES. 499 

be severed by inserting 1 the point of the knife below and cut- 
ting upward, and by hooking the knife around the anterior 
aspect of the long process of the incus and cutting downward. 
It is usually advised that the joint be opened from behind, 
the resistance offered by the stapedius muscle rendering this 
the simplest procedure. While this is theoretically correct, 
there are several objections to its performance. Frequently 
the long arm of the incus lies so near the margin of the ring 
that considerable force is necessary to introduce the knife 
behind it. If disarticulation is accomplished before the stape- 
dius muscle is divided, the retraction of this muscle may pull 
the stapes completely out of view and render subsequent mo- 
bilization impossible. It is advisable, therefore, to divide the 




Fig. 134. — Division of the stapedius 
tendon and of adhesions behind the 
stapes. 



Fig. 135. — Disarticulation at the incudo- 
stapedial articulation. 



stapedius tendon and the adjacent adhesions as the first step 
of the operation. This is done by inserting a sharp straight 
knife behind and above the head of the stapes, between it and 
the tympanic ring, carrying it inward until the point touches 
the inner tympanic wall, and then cutting directly downward 
{Fig. 134). By this procedure the stapes, and hence the ar- 
ticulation, is released and brought clearly into view by the 
traction of the tensor tympani muscle and of the cicatricial 
bands situated in the anterior part of the cavity. The ante- 
rior aspect of the descending cms of the incus is now in such 
a position that the joint may be easily divided by applying 
the ansfular knife to it and cutting downward and backward 
(Fig. 135), or in some instances it may be more convenient to 



500 MIDDLE-EAR OPERATIONS. 

enter the joint from below, with the point of the knife, sweep- 
ing the blade anteriorly and posteriorly until the capsular 
ligament is divided. After disarticulation the process of the 
incus is pushed upward and forward to prevent reunion." 
The stapes is next examined with a probe, the most suitable 
instrument being a fine cotton holder, the tip of which is 
firmly wound with a delicate pledget of cotton. If the ossicle 
is rigid, it is to be freed by passing the pointed knife about 
the foot plate, dividing all adventitious bands which may be 
found within the pelvis ovalis, passing from its walls to the 
crura of the stapes. After incision, mechanical mobilization 
by means of the cotton-tipped probe should be effected. The 
instrument is introduced below the stapes first, and an attempt 
made to crowd the ossicle upward by a leverlike action of the 
probe. The same manipulation is repeated from above down- 
ward, from behind forward, and from before backward, care 
being taken not to fracture the crura. Where the incudo- 
stapedial articulation is ossified, the long arm of the incus 
may be divided by a stout scissors,* the fragments being sepa- 
rated so as to prevent reunion, after which mobilization of the 
stapes is carried out after the manner described. 

In chronic nonsuppurative cases Miot + advocated the 
same procedure, the structures within the middle ear being 
exposed by an exploratory incision along the posterior margin 
of the membrana tympani, as already described in the tech- 
nique of exploratory myringotomy. General anaesthesia is 
not necessary either in the residual suppurative, or nonsup- 
purative cases. 

Mobilization in the nonsuppurative cases is less effectual 
if the exploratory incision is allowed to heal than where a per- 
manent opening is maintained, either by the removal of the 
entire membrane, malleus, and incus, or by allowing the flap to 
remain displaced, although by the latter procedure it is seldom 
possible to secure a permanent perforation. The lack of success 
when the flap is replaced is due to a recurrence of the condi- 
tion, the closure of the opening rendering it impossible to deal 
with this surgically except by repeating the original operation. 

(c) Plastic Operations for the Purpose of uniting the Incus or 
the Stapes to the Membrana Tympani Directly. — The object here 



* Politzer, Archiv fur Ohrenheilkunde. vol. xxii, p. 122. 
f Revue de laryngologie, 1890, p. 49 et seq. 



REMOVAL OF THE OSSICLES. 



501 



is to exclude the two larger ossicles from the physical process 
of sound conduction, so that the sound waves falling upon the 
membrana tympani shall act immediately upon the stapes. 
Little success has attended these procedures, although in ex- 
ceptional cases they may be valuable. 

A triangular flap of the membrane is turned aside from 
the posterior superior quadrant, exposing the incudo-stapedial 
articulation ; the mobility of the incus is determined by means 
of a probe ; adhesions about the stapes are severed according 
to the rules already laid down until this ossicle and the incus 
move freely. The triangular flap is then applied directly to 
the long arm of the incus and held in place by a small pledget 
of cotton or by a small paper dressing. If the incus can not 
be freed, disarticulation at the incudo-stapedial joint is per- 
formed and the flap applied to the head of the stapes instead 
of to the long arm of the incus. 

(d) Removal of the Ossicular Chain in its Entirety, or Removal 
of Individual Ossicles. — Removal of the ossicular chain may be 
attempted either for the improvement of hearing or for the 
relief of a long-continued suppurative process, or for both 
conditions. Since the technique is somewhat different, ac- 
cording as the condition results from a suppurative or non- 
suppurative inflammation, the operative procedure applicable 
to cases where the membrana tympani is intact will first be 
described in detail, after which attention will be given to the 
particular variations demanded in cases where there has been 
destruction of the membrana tympani over a large or small 
area. We have to consider, then — 

1. Removal of the malleus and incus. 

2. Removal of the malleus, incus, and stapes. 

3. Removal of the stapes. 

If the membrana tympani is present, this is also removed 
as completely as possible in carrying out the first two opera- 
tions, while in stapedectomy the membrane is allowed to 
remain. 

As early as 1873 Schwartze * advocated the removal of the 
malleus and the membrana tympani and disarticulation at the 
incudo-stapedial joint in cases of nonsuppurative inflamma- 
tion. Kessel f excised the membrana tympani, malleus, and 



* Arch, fur Ohrenheilk., vol. xxii, p. 12S. 
f Ibid., vol. xiii, p. 69. 



502 



MIDDLE-EAR OPERATIONS. 



incus, and mobilized the stapes in a case of complete stenosis 
of the Eustachian tube, while at an earlier date he had dem- 
onstrated that the stapes * might be evulsed from the oval 
window without serious consequences. In 1885 Lucae f re- 
ported fifty-three operations in nonsuppurative otitis media 
in which the membrana tympani and malleus had been re- 
moved and the incudo-stapedial articulation divided. In six 
of these cases the incus was also taken away. From this time 
on.the current literature contains numerous reports of removal 
of the ossicles in cases of nonsuppurative inflammation of the 
middle ear, the procedure being followed by varying degrees 
of success. 

Concerning the necessity of general anaesthesia, it may be 
said that at the present time the entire ossicular chain and the 
membrana tympani may be removed without the administra- 
tion of a general anaesthetic in patients having a fair amount 
of self-control. No discomfort is experienced during the en- 
tire procedure except at the moment of making the initial 
puncture, and, when the knife employed for the purpose is in 
perfect condition, the incision through the membrana tympani 
in the posterior segment just within the cartilaginous ring is 
not painful and sometimes is not felt. When the tympanic 
cavity has been entered the application of a ten-per-cent solu- 
tion of cocaine by means of a cotton-tipped probe renders the 
subsequent steps absolutely painless. It is necessary to pro- 
ceed slowly, as the local anaesthesia is confined to a limited 
area beyond the extent of the incision, and as the operation 
progresses the cocaine solution is to be applied from time to 
time to the edges of the wound and introduced into the tym- 
panic cavity through the artificial opening whenever the pa- 
tient gives evidence of feeling the manipulations in the slight- 
est degree. Naturally this prolongs the operation ; but the 
advantage gained of testing the results of the various steps 
of the operation, together with the increased delicacy of 
manipulation possible when the patient is conscious and able 
to maintain his head in any position in which it has been 
placed, more than compensates for the loss of time. 

Technique of the Removal of the Membrana Tympani and 
Ossicles whe7i the Membrana Tympani is hit act. — With the sharp 



* Arch, fur Ohrenheilk., vol. xi, p. 199. 
f Ibid., vol. xx, p. 228. 



REMOVAL OF THE OSSICLES. 



503 



knife (Fig. 123, e) an incision is made through the membrana 
tympani in the upper and posterior quadrant, commencing 
just below the point where the posterior fold meets the tym- 
panic ring, and following this curve, is carried downward 
to about the middle of the posterior border of the ring. 
This incision is made close to the insertion of the membrana, 
but should lie entirely in the clear membrane, for the reason 
that if this is done no haemorrhage results. For the same rea- 
son care must be taken not to wound the inner wall of the tym- 
panum with the point of the knife, as any bleeding greatly ob- 
scures the field of operation and renders the succeeding steps 
more difficult. The edges of the incision are now separated 
and the incudo-stapedial articulation is usually clearly and 
easily exposed. If sufficient space is not gained, a horizontal 
incision may be made from the upper extremity of the first, 
forward toward the short process of the malleus, the section 
following the course of the posterior fold and lying just be- 
low it, thus avoiding the more vascular tissues. If this does 
not give sufficient room the 
incision may then be carried 
downward just behind the long 
process of the malleus, as in ex- 
ploratory myringotomy (Fig. 
127). In this way a flap is 
formed which, on being turned 
downward, enables the opera- 
tor to see the incudo-stapedial 
articulation clearly (Fig. 136). 
The next step is the division 
of the stapedius tendon ; this 
may sometimes be seen run- 
ning from the neck of the stapes 
backward and disappearing be- 
hind the tympanic ring ; fre- 
quently, however, the head of 
the stapes lies so close to this 
structure that the tendon can 
not be seen ; in such a case the 

pointed knife used in dividing the membrana tympani is in- 
serted close to the head of the stapes and slightly above it 
and carried inward until the inner wall of the tympanum is 
reached ; a short cut downward is then made, carrying the 




Fig. 136. — Incudo-stapedial articulation 
exposed by displacement of a nap 
from the membrana tympani. 3, 
Horizontal incision at lower portion 
of membrane ; 2, The dotted line 
indicates the incision severing the 
peripheral attachment of the mem- 
brane. 



504 MIDDLE-EAR OPERATIONS. 

knife between the head of the stapes and the tympanic ring, 
while the point is still firmly pressed upon the inner wail of 
the tympanum (Fig. 134). In this way the muscle is thor- 
oughly divided. When the tendon can be seen its division is 
perhaps more simple ; but in either case the point of the knife 
should be firmly pressed against the inner wall of the tym- 
panum, in order that the tendon and any adhesions about it 
may be thoroughly and completely severed. 

As soon as this has been done the action of the tensor tym- 
pani will bring the incudo-stapedial articulation and the stapes 
more clearly into view. The next step is the division of the 
incudo-stapedial articulation which is effected with the angu- 
lar knife. The knife is inserted into the handle in such a way 
that the point is directed backward and is carried into the 
tympanic cavity in front of the long arm of the incus, and the 
blade passed to the inner side of this process (Fig. 135); by 
slight pressure backward the shaft of the instrument is kept 
close to the descending process of the incus, while at the 
same time the instrument is pressed inward, so that the an- 
gular blade will lie against the internal tympanic wall ; the 
articulation is divided with a downward stroke. If fibres of 
the capsular ligament still remain undivided posteriorly the 
angular knife is to be turned in an opposite direction, with 
the point directed forward, when, by passing it behind the 
long process of the incus, a downward stroke will complete 
the division. 

If these steps have been carried out as indicated it will be 
the exception if more than a drop of blood has been lost. 

Next, with the pointed knife, a short, horizontal incision is 
made through the membrana tympani at its most dependent 
part close to the insertion into the annulus tympanicus (Fig. 
x 36> 3) ; the pointed knife is quickly laid aside and the probe- 
pointed knife (Fig. 123, c) is inserted, and the membrane is 
divided along its posterior periphery from below upward 
until the exploratory incision is encountered. In the same 
manner the anterior segment of the membrane is divided from 
below upward with the probe-pointed knife, the incision ex- 
tending as far as, but not into, Shrapnell's membrane. (The in- 
cision is indicated by the dotted line, 2, in Fig. 136.) Up to 
this point no blood has been lost and the field of operation 
is as clear as when we started. There remains to be divided 
the membrana flaccida and the ligaments which bind the mal- 



REMOVAL OF THE MALLEUS. 505 

leus externally, in front and behind. The pointed knife is 
again used for this section, which should be made rapidly. 
The knife is held so that the flat surface of the blade looks 
toward the roof of the canal, the cutting edge being directed 
backward ; the point of the knife is entered just above the 
short process of the malleus and is pushed inward and up- 
ward, the handle being depressed so that the shaft often 
touches the margin of the speculum. In this manner the 
knife is made to enter the fornix tympani ; it is now made 
to cut its way out, downward and backward, thus severing 
the external and posterior ligaments of the malleus and di- 
viding the membrana flaccida posteriorly. The knife is then 
quickly turned and made to cut in the opposite direction, 
being carried forward over the short process, dividing the 
anterior segment of the membrana flaccida, some fibres of 
the external ligament, and the strong anterior ligament of the 
malleus. The malleus is now held only by the superior liga- 
ment and the tendon of the tensor tympani, neither of which 
is strong. The haemorrhage from the last incision may be free 
and may obscure the field, but usually, owing to the elevated 
position of the head, the upper part of the field is not obscured, 
and the short process of the malleus can be distinctly seen. 
The ossicle is quickly grasped with the forceps (Fig. 137), just 
below the short process, and by pressing inward to dislodge 




Fig. 137. — McKay's ear forceps. (The blades 
should be about half an inch longer than in the 
forceps usually sold under this name.) 



the neck of the bone from the projection upon which it rests, 
followed by traction downward and then outward, the ossicle 
is extracted. No force is required to rupture the tendon of the 
tensor tympani or the superior ligament, as they offer very lit- 
tle resistance. 

It will be necessary now to wipe out the blood which has 
followed the removal of the malleus, but in most cases a single 
pledget of cotton will dry the cavity completely. The incus 

34 



; 3c 



MIDDLE-EAR OPERATIONS. 



is next sought for. and. if in sight, is grasped with the forceps 
and removed, traction being at first exerted downward and 
forward and then outward. Most frequently when the incus 
is in view the long process will be seen, not in the normal 
location, but lower down and lying close to the border of the 
tvmpanic ring — so close, frequently, that it is overlooked., for 
.en apparentlv constitutes a part of the ring. Manipula- 
tion by means of a probe reveals its identity and the ossicle 
can be extracted in the manner already described. This dis- 
placement of the incus downward and backward is due to the 
fact that in the removal of the malleus the capsular ligament 
binding the two ossicles together must be ruptured. The 
incus itself is attached to the tvmpanic wail by means of a 
single ligament running from its short process to the walls of 
the fornix tvmpani. Traction downward on the malleus dis- 
places the incus downward and also revolves it backward, the 
short process being the fixed point. Thus frequently, after 
the malleus has been removed, careful inspection of the field of 
operation fails to reveal any trace of the incus, it having been 
rotated entirelv out of sight behind the tvmpanic ring. To 
effect its extraction is not alwavs easy, and vet in cases where 
there has been no suppuration it will rarelv happen that the 
ossicle will escape. When not in sight the long process of the 
incus can be easily brought into view by means of the incus 
hooks 'Fig. 125.7 and ^)« These hooks are curved in oppo- 
site directions for the right and left ear. the concavitv of the 
curve looking anterioriv in each case : the instrument is in- 
serted into the handle with its angular extremitv directed 
upward. The incus hook is introduced into the tvmpanic 
cavity and the angular portion passed behind the tvmpanic 
rinsr close to the floor of the canal, the hook beins: inserted 
in such a way that the concavitv of the hook looks upward. 
When the angular portion of the instrument has entirelv dis- 
appeared behind the ring the instrument is drawn outward 
until it is felt to press closelv upon the inner surface of the 
tympanic ring, when it is rotated forward, at the same time 
being carried a little upward. Usually this manipulation 
swings the long arm of the incus into view (Fig. 138 . The 
difficulty sometimes experienced in securing the incus usu- 
ally lies in the fact that the operator is inclined to search 
for the ossicle too high up in the tvmpanum and to forget 
that the long process lies close to the margin of the ring ; 



REMOVAL OF THE INCUS. 



507 




Fig 



Incus hook in position. 



the hook is therefore frequently carried too deeply into the 
tympanic cavity and fails to engage the long process. This 
manoeuvre is to be repeated several times in case the first effort 
is not successful. If no free body 
is felt with the hook it is then 
inserted into the tympanum at 
the anteroinferior portion with 
the concavity of the hook di- 
rected posteriorly ; the hook is 
now rotated, sweeping the ex- 
tremity which touches the tym- 
panic ring closely, backward, 
and at the same time somewhat 
upward. This manipulation will 
bring the incus into view in case 
rupture of the posterior ligament 
of the incus during the removal 
of the malleus has allowed the 
ossicle to fall into the antero- 
inferior part of the tympanic cavity, an accident which may 
sometimes happen. 

If the ossicle is not found in either of these situations, the 
hook should be swept upward and forward through the pos- 
tero-superior and superior portions of the tympanic cavity, 
keeping it still pressed firmly against the internal margin of 
the ring. Care is to be taken in this manipulation that the 
hook does not pass between the crura of the stapes or frac- 
ture them as it is carried forward. If the incus still remains 
hidden, the hook having the opposite curve should now be 
carried into the fornix tympani with the concavity directed 
backward, the angular portion of the instrument being 
hooked behind the inner extremity of the superior wall of 
the meatus. The instrument is now rotated backward, and 
at the same time is carried downward, rotation being con- 
tinued through an angle of one hundred and eighty degrees. 
This manipulation will dislodge the incus in cases where its 
posterior ligament is very strong, or where the long process 
has been rotated far backward out of reach of the hook. 
After this downward sweep it is well to repeat all of the 
steps for dislodging the incus in the order named, as this last 
manipulation may displace the ossicle downward, although it 
may still remain hidden from view. The objection to begin- 



508 



MIDDLE-EAR OPERATIONS. 



nino- the search in the manner last mentioned lies in the fact 
that, if the ossicle is already free or nearly so, the manipula- 
tion is apt to displace it so far toward the mastoid antrum as 
to render it entirely inaccessible. I have written upon the 
method of extracting this ossicle somewhat at length, because 
I believe it to be extremely important to remove it if pos- 
sible ; and I feel certain that the advantages gained by its 
extraction are more than enough to warrant prolonging the 
operation for this purpose. 

After the incus has been removed, the cavity is thoroughly 
dried and the region of the round window inspected. Any 
thickening in this situation should be overcome by cutting 
away the hypertrophied tissue if possible. Usually, however, 
we find simply a thickening of the mucous membrane about 
the fenestra. Stellate incisions by means of an angular knife 
(Fig. 123,/and £*,), introduced into the niche, most frequently 
relieve the tension. 

The stapes is next inspected and its mobility tested. If 
rigfid, all adhesions about it should be divided and the ossicle 
mobilized with the cotton-tipped probe, in the manner already 
described ; if its motion is now free, the operation may be 
considered completed. If, on the other hand, the motion of 
the stapes is still impeded, or if the adhesions have been found 
to be so extensive that, after they have been divided, cica- 
trization will probably render the ossicle rigid again, the 
stapes may be removed. All soft tissue binding it down 
should be carefully severed with the sharp knife passed 
around the foot plate, after which a delicate hook (Fig. 123, 
b) is passed between the crura and the ossicle is removed by 
traction. It is often more easy to grasp the head of the bone 
with the forceps and remove it in this way than by making 
use of the hook. 

In cases where difficulty is experienced in finding the 
incus, and it is deemed necessary to remove the stapes — this 
ossicle being easily seen — it is often wise not to delay the 
removal of the stapes until the incus is found, since, in the 
manipulations necessary to displace the incus, the crura of 
the stapes might accidentally be broken or the head of the 
bone be so displaced as not to be easily seen. Hence, if the 
incus is not readily found, and it has been found advisable to 
extract the stapes, this may be removed as the second step 
of the operation, and the incus subsequently searched for. 



REMOVAL OF THE INCUS. 



509 



If the stapes is removed at this stage of the procedure, care 
must be taken in searching for the incus that the incus hook 
is not passed through the oval window, thus injuring the 
labyrinth. This may seem a needless precaution ; but any 
one who has studied the parts upon the cadaver will appre- 
ciate how easily the incus hook can be passed through the 
thin membrane covering the fenestra ovalis. The reason of 
this lies in the fact that the plane of the oval window is not 
vertical, but inclined downward and outward. When this 




Fig. 139. — Author's cutting forceps for the removal of a portion of the inner ex- 
tremity of the external auditory canal. 

opening is situated high up, and is almost hidden bv the tym- 
panic ring, the incus hook may be easily carried under its 
upper margin and through the membrane covering the open- 
ing, the operator mistaking the resistance offered for that of 
the tympanic ring. If the posterior wall of the canal is closely 
followed and the incus hook made to enter the tympanum 
low down, and is afterward applied closely to the tympanic 
ring, this accident can not occur. 



5io 



MIDDLE-EAR OPERATIONS. 



In some instances the margin of the tympanic ring hides 
the stapes so completely that this ossicle can not be seen, and 
it is impossible to form an intelligent opinion as to its condi- 
tion or to effect its removal. In such an event the margins 
of the ring in this situation may be cut away by means of the 
forceps shown in Fig. 139. This forceps is so constructed 
that when open the distal extremity of the lower blade can 
be passed up behind the tympanic ring. Upon closing the 
instrument, the chisel blade cuts away a small chip from 
the overhanging wall. By repeating this procedure enough 
space can be gained to permit of access to the stapes and 
oval window. 

Occasionally the foot plate of the stapes will be found to 
be so firmly fixed in the oval window that it can not be loos- 
ened, and that after dividing all adhesions its removal is im- 
possible, the crura sometimes being broken in the attempt at 
extraction. In such an event the operator should proceed 
with the greatest caution. All the soft tissues should be care- 
fully removed from the oval niche by means of the angular 
knives (Fig. 123,/,^*) and a delicate curette (Fig. 123, a). If 
the outline of the foot plate can now be made out, a pointed 
knife should be carried around its periphery in the hope of 
making an opening at some point where the union is less firm ; 
through such an opening a delicate hook can be introduced 
and a part at least of the foot plate brought away. If com- 
plete ossification has taken place I should advise the cautious 
use of a small guarded drill, which might be made to perforate 
the foot plate at its centre, after which portions might be re- 
moved with the hook. I have never had occasion to do this 
upon the living subject, but should not hesitate to do so, 
using, of course, great care. It would be possible to carry 
out this step without evacuating the perilymph ; but even if 
a small quantity of the fluid should be lost, Kessel's observa- 
tions have proved that no harm results. It need hardly be 
said that such interference is justifiable only in cases where 
absolute asepsis has been preserved. 

After all the operative steps deemed necessary have been 
carried out, the cavity is to be dried with pledgets of cotton 
and a tampon of iodoform gauze or a long pledget of cotton in- 
troduced. This is carried completely into the tympanum and 
should fill the canal but loosely. The object of the gauze is 
to check any oozing which ma) 7 occur and to serve as a drain, 



TREATMENT AFTER OPERATION. 511 

thus preventing the formation of a blood clot within the mid- 
dle ear ; if this is allowed to form it may give rise to consider- 
able pain by preventing the escape of secretion during the first 
days after the operation. If there is much pain a few hours after 
the operation this tampon is removed and the ear is douched 
with a warm, weak antiseptic solution (as, for instance, a satu- 
rated solution of boric acid or a solution of bichloride of mer- 
cury, 1 to 8,000), after which the tampon is reinserted. When 
the odor of iodoform is objectionable, sterilized or borated 
gauze may be used. This second tampon is allowed to remain 
in position for twenty-four hours, and in cases where there is 
no pain after the operation the first tampon is not disturbed 
for twenty-four hours. This tampon is placed so deeply as to 
be out of the reach of the patient, while a pledget of cotton is 
placed at the orifice of the meatus to collect any serous transu- 
date. The patient is allowed to change this outer pledget as 
often as it becomes saturated, but leaves the deeper one undis- 
turbed. The subsequent treatment depends upon the amount 
of local reaction following the procedure. If there is but lit- 
tle discharge, the cleansing of the ear once daily by the sur- 
geon, followed by the insufflation of boric acid, dermatol, or 
some kindred powder, will be all that is necessary. If the 
mucous membrane over the internal tympanic wall appears 
healthy and there is little or no secretion, the best results will 
be obtained by keeping the canal aseptic by gently wiping the 
wails with a solution of bichloride of mercury (1 to 5,000) in 
•fifty -per-cent alcohol, leaving the tympanic cavity undisturbed. 
If any powder is insufflated it should in these cases be applied 
to the walls of the canal only, and should not enter the tym- 
panum. When the middle ear is not inflamed, any interfer- 
ence retards the progress of the case rather than favors it. If 
the patient can not be seen daily, as is usually the case in dis- 
pensary practice, gentle syringing of the ear once or twice 
daily, according to the amount of discharge, if any appears, is 
all that will be required, but I have never thought it wise to 
trust the insufflation of any powder to the patient. When the 
discharge is only slight, even the syringing is objectionable, 
and an intelligent patient may be allowed to cleanse the ear 
by simply wiping it out with a pledget of cotton wound upon 
an appropriate cotton holder. On the other hand, if at the 
end of a week there is still considerable secretion, the patient 
is directed to instill a few drops of a solution of boric acid in 



5 I2 MIDDLE-EAR OPERATIONS. 

alcohol of a strength of twenty grains to the ounce, after each 
syringing. The amount of discharge after the operation will 
depend upon the habit of the patient and also upon the condi- 
tion of the mucous membrane of the tympanum. In cases of 
advanced sclerosis the amount is frequently insignificant, espe- 
cially if the patient is not of a full habit. On the other hand, 
when the tympanic cavity or the fornix tympani has been full 
of connective tissue rich in blood vessels, the discharge fol- 
lowing the operation will be more profuse. It is probable, 
also, that prolonged manipulation within the cavity at the time 
of the operation favors a more profuse discharge, although 
this is certainly not true in all cases, and should not deter the 
operator from doing a deliberate and thorough operation. 

I have written somewhat at length about the management 
of the cases after operation because I consider this an impor- 
tant point. In a general way, the less that is done after the 
operation, the more likely we are to obtain a permanent open- 
ing into the tympanic cavity, a condition always to be desired. 
Hence the aim should be to keep the ear clean with as little 
manipulation as possible, and to avoid the use of astringents 
or caustics to stop the discharge, since they will certainly pro- 
mote the reproduction of the tympanic membrane. 

The amount of disturbance caused by the procedure de- 
scribed is very slight. Of forty cases, both purulent and non- 
purulent, thirty-five left the hospital twenty-four hours after 
the operation and resumed their regular daily work without 
the least trouble, and quite a number returned home upon the 
evening of the same day, the operation having been performed 
in the afternoon. Of course the stapes was not removed in all 
of these cases ; and when this ossicle is taken away I prefer to 
confine the patient to the house for twenty-four hours at least. 
Yet in three cases of stapedectomy the patients returned 
home in less time than this without any unpleasant effects, 
while in two cases in which this ossicle was left in situ, but 
had been subjected to considerable manipulation in securing 
the incus, dizziness persisted for several days after the opera- 
tion. As a rule, when the two larger ossicles alone are to be 
excised, the patient can be assured that any disturbance suf- 
ficient to incapacitate him for work will not last more than 
twenty-four hours — an item of importance among those who 
find it impossible to obtain a longer respite from their daily 
vocation. Of this we can be as certain as in allotting the same 



REPRODUCTION OF THE MEMBRANE. 



513 



period for the disappearance of the unpleasant effects of gen- 
eral anaesthesia, and the surgeon is justified in promising that 
the effects of the operation will not detain the patient after the 
disturbance due to the anaesthetic has passed away. 

When the stapes is to be removed, however, the dizziness 
may make locomotion difficult for a somewhat longer period, 
and if there is a probability that this will supervene it is not 
wise to promise that this giddiness will not interfere with lo- 
comotion for several days, although in many cases the giddi- 
ness will disappear rapidly. If the malleus and incus alone 
are removed it will be decidedly rare for any such disturb- 
ance to follow. 

I have never met with pain or severe local inflammation as 
the result of these operations, for the reason, I believe, that 
perfect drainage exists. In this respect I feel certain that the 
complete removal of the ossicles and membrane commends 
itself, when compared with some of the intratympanic opera- 
tions in which less positive violence is done but in which free 
drainage is not secured. 

As regards the reproduction of the membrana tympani, 
my experience has been that, as a rule, the membrane 
will reform, although this is not always the case. The 
membrane which reforms is usually thin and not as sensi- 
tive as the normal membrane, and its removal is but a trivial 
measure. Again, its reproduction does not always impair 
the result of the operation. In cases, however, in which, 
after the membrane has been reproduced, the hearing be- 
comes worse than while a perforation was present, it should 
be removed. General anaesthesia, in my experience, has 
never been necessary. The first incision through the mem- 
brane is slightly painful, after which a few drops of ten- 
per-cent aqueous solution of cocaine introduced into the tym- 
panic cavity by means of the cotton-tipped probe renders the 
remainder of the operation painless. If previous experience 
has shown that cocaine produces unpleasant constitutional 
symptoms, a saturated solution of eucaine (B) may be used. 
The operation is best performed by passing the sharp 
knife (Fig. 123, e) through the membrane close to the tym- 
panic ring and just below the head of the stapes and di- 
viding the posterior attachment of the membrane close to 
the ring for a short distance, great care being taken not to 
wound the mucous membrane of the tympanum. The probe- 
pointed knife should then be substituted and the attachment 



5*4 



MIDDLE-EAR OPERATIONS. 



followed downward to its lowest point. It will then be found 
that the tissue is so relaxed that division of the anterior at- 
tachment is difficult ; to overcome this the sharp knife is again 
passed through the membrane at its lower part just in front 
of the point where the posterior incision terminated. A little 
pain is usually experienced from the incision, but it is only 
momentary. The anterior attachment is now divided from 
below upward with the blunt knife until the incision meets 
that which severed the posterior attachment. Usually the re- 
laxation interferes with the complete section'. The membrane 
is now held by a thin strip of tissue above and below. A touch 
with the sharp knife severs these attachments or weakens them 
to such an extent that the entire membrane may be easily re- 
moved with the forceps. If it is too firmly held, the small scis- 
sors (Fig. 128) will be found useful. The procedure is so sim- 
ple that, if attention is given to secure an aseptic condition of 
the instruments and field of operation, no reaction results. The 
operation may safely be performed at the office of the physi- 
cian and the patient at once allowed to resume his usual duties. 
It is well to protect the ear by the insertion of a cotton pledget 
which need not be worn for more than forty-eight hours after 
the removal of the new membrane. After this it is well for 
the patient to occlude the meatus with a cotton pledget when 
out of doors. At the end of five or six days no protection is 
necessary. The patient should be cautioned against taking 
•cold ; but further than this no special precautions are to be 
advised. The procedure is not likely to be followed by any 
discharge, and all syringing of the ear is to be avoided unless 
pain or profuse discharge supervene, as disturbing the parts 
in any way may excite enough reaction to cause a reproduc- 
tion of the membrane. 

One point is worthy of special attention, and that is that 
the removal of a membrane which has formed after operation 
should not be undertaken until all traces of inflammation have 
disappeared. The surgeon must wait until the newly formed 
tissue is pearly white and glistening and until the mucous lin- 
ing of the tympanum has also assumed its normal condition, 
as evidenced by the absence of redness, engorgement of its 
vessels being easily made out through the thin cicatricial mem- 
brane. If this rule is not observed the operation will be more 
painful, and reproduction is almost certain. If the membrane 
reform again, a second or third removal is still more simple, as 



TREATMENT OF SECONDARY MEMBRANE. 



5' 



the density of the tissue is less each time that it is reproduced. 
In one case this was so marked that after the first incision the 
edges of the wound retracted so widely that it was possible 
to remove only a minute portion of the new-formed tissue, and 
yet the tympanum was freely exposed, and no reproduction 
has followed at the end of several months. 

In plethoric individuals a persistent reproduction of the 
membrana tympani after excision can be prevented by a re- 
striction of the diet for a few weeks previous to and following 
the secondary removal of the structure. This is suggested 
by Sexton,* and I have proved its efficacy. 

In certain instances it may be found that the new mem- 
brane has become adherent to the inner wall of the tympa- 
num, thus rendering its complete removal difficult. In one 
such case in which the stapes had been left in situ, the hearing 
remaining impaired, apparently on account of the stapes being 
bound down by the newly formed membrane, this was divided 
first behind the head of the stapes and the incision was car- 
ried downward close to the tympanic ring for a distance 
equal to about one third its posterior margin. The stapes 
then lay free, while in front there was a flap attached by adhe- 
sions to the inner tympanic wall ; this flap was turned forward 
and the underlying wall of the tympanum was scarified, after 
which the flap was replaced and pushed down upon the wall 
of the middle ear, care being taken that the free margin lay 
below the tympanic ring. Adhesion at once resulted, leaving 
the stapes projecting into the canal, while the tympanic cavity 
was largely obliterated from the adhesion of the membrane to 
its inner wall. Thus the middle ear was thoroughly protected 
by a cutaneous covering, while the parts essential to audition 
remained accessible for further operative procedure. The 
patient, though better, is still under treatment, and I hope for 
still further improvement following the division of remaining 
bands which partially fix the stapes. It may be advisable in 
certain cases to preserve the anterior portion of the membrana 
tympani in removing the malleus and incus, and, after scarifi- 
cation of the inner wall of the tympanum, to attempt to secure 
adhesion of the anterior segment of the membrana to this 
structure. In this manner we might shut off the anterior 
part of the tympanic cavity from the posterior portion which 

* The Ear and its Diseases, New York, iSSq, p. 302. 



516 MIDDLE-EAR OPERATIONS. 

contains the parts especially concerned in audition. The pos^ 
terior portion would become covered by epithelium from 
the surface of the membrana tympani, and the objection of 
having an exposed mucous surface would be avoided. We 
could by care secure a thin epithelial covering for the round 
and oval windows, the stapes being removed or not, according 
to indications. I have never performed the operation with 
this object in view, but, from the fact that Nature occasionally 
succeeds in doing this unaided, it may not be out of place to 
suggest it here as worthy of a trial. 

Technique of Operation where the Membrane is Partially or 
almost Completely Destroyed. — Where the ossicles are to be re- 
moved for the relief of a purulent inflammation general an- 
aesthesia should be employed, since removal of the ossicles 
alone constitutes but a small part of the operation. The 
pathological process is seldom confined to these structures, 
but has involved as well the bony walls of the tympanic cav- 
ity, and it becomes necessary to curette thoroughly the entire 
space if the process is to be permanently checked. In these 
cases also the malleus and incus are frequently destroyed in 
large part, nought but minute fragments remaining. To se- 
cure these fragments, prolonged, and sometimes forcible, ma- 
nipulation becomes necessary, and a thorough operation is 
possible only under general anaesthesia. 

When a purulent inflammation has resulted in the destruc- 
tion of a considerable portion of the membrana tympani, the 
method of procedure must be modified to a certain extent. 
In some of these cases we shall find the lower portion of the 
membrana wanting, the membrana flaccida thickened and 
highly vascular, binding the ossicles down and concealing 
them more or less completely. We may be able to recognize 
by inspection only the prominent short process of the malleus 
and a portion of the manubrium, the latter lying almost hori- 
zontal, its tip bound firmly to the upper part of the inner 
tympanic wall. Behind the short process examination with a 
probe reveals the incus and stapes as present, but whether in 
their entirety or not can not be determined. In other cases, 
while there may have been extensive destruction of the mem- 
brana tympani, the posterior superior segment is covered with 
a thin cicatricial membrane, through which the incudo-stape- 
dial articulation is plainly seen, or this joint may be com- 
pletely exposed, no covering being present. My rule has been, 



TECHNIQUE IN SUPPURATIVE CASES. 5^ 

in all cases where the incudo-stapedial articulation is visible, 
or where this region is covered by a nonvascular membrane 
the division of which will not lead to annoying haemorrhage, 
to divide first the stapedius muscle and then the incudo- 
stapedial articulation in the manner described when consider- 
ing the method of operation in cases in which the membrana 
is intact. When, however, it is evident that an incision in 
this region will be followed by haemorrhage, such a step serves 
only to complicate the operation, as the bleeding will render 
it impossible to see the incudo-stapedial joint, much less to 
disarticulate with certainty, and will frequently completely 
obscure the field of operation, hiding even that most promi- 
nent and important landmark, the short process of the mal- 
leus, so that considerable difficulty may be experienced in 
removing even this ossicle. Experience shows us that when 
this condition is present there is very little haemorrhage after 
the membrana flaccida has been completely freed from its 
attachments and removed, together with the malleus. Our 
first step, then, will be to insert the straight pointed knife 
above the short process, pushing it inward and upward until 
the inner wall of the tympanum is encountered ; it is then 
made to divide rapidly the attachments of the remnant of the 
membrane to the tympanic ring by directing its edge back- 
ward and incising close to the margin of the ring ; without 
removing it from the wound, the edge is turned in the oppo- 
site direction and divides the anterior attachments. In cut- 
ting backward, the operator must bear in mind that the in- 
cudo-stapedial articulation has not been severed, and in this 
region as little force as possible should be used. For this 
reason, also, the posterior incision should be made first as 
above directed. Almost immediately the fundus of the canal 
fills with blood, but for a few seconds at least the short pro- 
cess is plainly visible ; and if examination has shown us that 
the manubrium is not firmly bound to the promontory, the 
malleus is at once seized with the forceps just below the short 
process and removed in the manner already described. If, 
however, firm adhesions are known to exist, or if the mal- 
leus is found to be firmly fixed on grasping it with the for- 
ceps, no force should be used to effect its removal, but the 
canal should at once be tamponed firmly with cotton bv car- 
rying an elongated plug into the tympanic cavity with the 
forceps and pressing it firmly upon the tympanic wall, the 



5 i3 



MIDDLE-EAR OPERATIONS. 



remainder of the plug being then forced inward. Upon 
this tampon a second and third are crowded until there is no 
bleeding about the plugs. If this packing is allowed to re- 
main in position for a few moments and then removed with 
the forceps, the held of operation will be found to be dry, the 
bleeding having been entirely checked. Any given area can 
be more completely cleansed by touching it with a small 
pledget wound upon a cotton-holder. The adhesions binding 
the malleus to the promontory can now be divided with the 
blunt knife curved on the flat, after which the ossicle is re- 
moved bv means of the forceps. If the malleus is still firmly 
fixed, manipulation bv means of the probe will determine the 
situation of the undivided attachments and their section can 
be effected. 

When it has been possible to divide the incudo-stapedial 
articulation as the initial step, I frequently remove the malleus 
in the manner described as the second step of the operation, in 
place of the first, after freeing the remnant of the membrane 
from its peripheral attachments below, anteriorlv and posteri- 
orly. This, of course, applies to cases in which the greater por- 
tion of the tympanic membrane has been destroved. When 
only a comparatively small portion of the membrana vibrans is 
wanting and excision is deemed proper, it may be well, after 
dividing the incudo-stapedial articulation, to sever the pe- 
ripheral attachments of the membrane from below upward bv 
means of a blunt knife introduced through the perforation. 
As a rule, however, so many adhesions exist between the 
inner tympanic wall and the lower portion of the membrana 
that such a procedure is unadvisable. Moreover, the parts 
are frequently so vascular that the attendant bleeding may 
complicate the more important part of the procedure — the 
division of the superior attachments and the removal of the 
malleus. It is usually wiser in these cases to divide the upper- 
segment first, the knife being carried into the perforation in 
terminating the posterior and anterior incisions. 

It mav seem hazardous to subject the stapes to the possi- 
bilities of violence attendant upon removal of the malleus be- 
fore the incudo-stapedial articulation has been divided. A 
moment's reflection will convince one, however, that the 
presence of firm connective tissue which renders the proce- 
dure necessary also fixes the stapes so firmlv that intelligent 
manipulation can scarcely displace it. while the danger of in*- 



OBSTACLES TO THE REMOVAL OF THE INCUS. 



519 



flicting such an injury is much greater if an attempt is made 
to divide the articulation with the field of operation partially 
obscured by blood. Again, it frequently happens that the 
long process of the incus has become necrotic and the articu- 
lation has been destroyed, so that no connection between the 
two ossicles exists. 

After the malleus has been removed, the stapedius muscle 
and incudo-stapedial articulation should be found and divided, 
unless this step has already been performed, after which 
search is made for the incus in the manner already fully de- 
scribed. It should be remembered that as caries more fre- 
quently attacks the incus than any other ossicle, it may be 
partially or completely destroyed. In the former case its re- 
moval is often difficult, while it is important to determine with 
certainty the latter condition, to avoid a prolonged search if 
it is absent. It should also be borne in mind that the patho- 
logical process may have resulted in a bony union between 
the incus and malleus, and that both ossicles may be extracted 
together. In case both ossicles were intact, the operator could 
not overlook such an occurrence ; but when one or both have 
been partially destroyed, careful inspection of the portions re- 
moved may be necessary, to determine the simultaneous re- 
moval of the malleus and incus. The operator should then, 
upon extracting what he supposes to be the malleus, carefully 
examine it, in order to assure himself that the body of the incus 
is not attached thereto. If nothing but the malleus is found, 
the field of operation should be dried and inspected carefully. 
If no portion of the incus is seen, special attention should 
next be given to the postero-superior segment of the field. It 
sometimes happens that the incision has not been close to the 
tympanic ring in this region, a circumstance not easily recog- 
nized unless the parts are touched with the probe, when it will 
be found that a small curtain, or flap, of tissue remains undi- 
vided. The destruction of a small part of the ring at this point, 
as the result of caries, also gives rise to a similar appearance. 
It quite frequently happens that the incus is adherent to this 
flap, or completely concealed by it. Division of the soft parts 
close to the bony margin will, in such a case, bring the incus 
into view. If not found in this situation, the ossicle must be 
searched for with the incus hook, in the manner already de- 
scribed while considering the operation in cases with an 
intact membrana tympani. If all of these manipulations fail 



520 



MIDDLE-EAR OPERATIONS. 



to bring the incus into view, or if it has not been felt, and the 
incus hook can be carried freely from behind forward, through 
the vault of the tympanum, the operator may decide that the 
ossicle has been destroyed by caries, or that it has suffered 
partial destruction, and the remaining portion has become amal- 
gamated with the tympanic roof. If, however, it has been seen 
or felt at any time, its subsequent loss will mean dislocation into 
the mastoid antrum. 

The management of the stapes and the region of the round 
window is conducted in the manner already described. 

Any parts of the membrana tympani which may remain in 
the lower portion of the fundus are to be removed with the 
knife, curette, and forceps if they are the seat of a hypertrophic 
process, as evidenced by considerable thickening and increased 
vascularity, for they may conceal areas of bony necrosis. If, 
however, the appearance of the lower portion of the mem- 
brane is healthy, we may feel certain that the bony structures 
are unaffected, and that there is no indication for the removal 
of the lower portion of the membrane — in fact, its presence 
will hasten cicatrization. 

After drying the tympanum thoroughly, we should next 
search for softened bone, both by inspection and with the probe. 
Inspection will often reveal here and there unhealthy granu- 
lation tissue indicative of the presence of dead bone. The probe 
should be made to traverse carefully the entire inner wall of 
the tympanum, and should also be bent at a right angle at 
the tip, to enable the surgeon thoroughly to explore the tym- 
panic vault. The curette should then be freely used, and all 
granulation tissue and softened bone should be removed. For 
the atrium the straight curette (Fig. 123, a) will be found serv- 
iceable, but for the vault the sharp spoons, bent at a right angle 
(Fig. 123, h, i), must be called into requisition. This procedure 
of thoroughly removing exuberant granulations and curetting 
the walls of the entire cavity is of the greatest importance, and 
should be conducted with special care, as the ultimate success 
of the operation often depends quite as much upon this step 
as upon the removal of the ossicles. An area of softened bone 
in the vault of the tympanum will keep up the discharge for 
a long time, and render the result of the operation far from 
satisfactory. Hence quite as much attention should be given 
to this procedure as to the removal of the ossicula. The curette 
should also be introduced well into the tympanic orifice of the 



TREATMENT AFTER OPERATION. 521 

Eustachian tube, so as to cause a closure of this tube, if possible, 
to prevent subsequent infection of the middle ear from the naso- 
pharynx. After the bony walls of the tympanum have been 
thoroughly curetted, the margins of the tympanic ring should 
receive attention. It frequently happens, when long-continued 
suppuration has existed, that the margin of the ring becomes 
involved. This is particularly true of the superior and postero- 
superior margin, on account of its intimate relation to the ossic- 
ula, and because it forms a portion of the floor of the vault of 
the tympanum. Any roughness or softening in this region 
should be dealt with radically. All diseased areas should be 
removed with a curette, and a portion of the ring may be excised 
with the cutting forceps if necessary. 

After all these steps have been carried out, the treatment 
of the case for the first twenty-four hours will not differ from 
the after-treatment of cases in which the membrana tympani 
was originally intact. The treatment subsequent to the first 
twenty-four hours, however, must vary with each individual 
case. AVhile the discharge continues profuse, the ear must be 
cleansed by the patient with the syringe and a mild antiseptic 
solution twice daily, or more frequently if this is necessary to 
keep the parts clean. At the end of a week, if there is con- 
siderable discharge, I recommend the instillation of the solu- 
tion of boric acid in alcohol twice daily after thorough cleans- 
ing. Any granulation tissue must be destroyed, as it appears, 
by means of chromic acid, silver nitrate, the actual cautery, 
or any other destructive agent. 

As the discharge becomes almost nil we may dispense with 
the syringe, and the patient may be allowed to cleanse the ear 
by means of pledgets of cotton wound upon any convenient 
probe, while the surgeon may once or twice weekly insufflate 
a small quantity of boric acid, dermatol, or other mild antiseptic 
or stimulating power, until all discharge ceases. 

It has been my good fortune in the majority of such cases 
either to stop the discharge completely or to diminish it so 
much that it has ceased to be a source of annoyance. The 
length of time which must elapse after the operation before 
complete cessation of the discharge must vary with each 
case, depending upon the extent of the original involve- 
ment. Where the caries has invaded the tympanic walls 
the discharge will naturally persist for a longer period 
than when the disease has been limited to the ossicles. 

35 



522 MIDDLE-EAR OPERATIONS. 

From six to eight weeks is the average time. In some cases- 
cicatrization may be perfect at the end of two or three weeks,. 
while in others the same number of months must elapse. 

The technique given varies in some particulars from that 
advocated bv other operators. In the division of the incudo- 
stapedial articulation the ordinary direction is to enter the 
knife behind the long arm of the incus and divide the articu- 
lation bv cutting downward and forward. Those who advo- 
cate this plan of procedure say that the pressure of the instru- 
ment is then opposed by the action of the stapedius muscle,- 
and danger of injury to the stapes is avoided, while at the 
same time the resistance of the stapedius renders the division- 
more easv. My own preference is to sever completely the 
stapedius tendon before attempting to disarticulate, as by this 
means the articulation is brought more perfectly into view 
through the action of the tensor tympani and tense ligament- 
ous bands located anteriorly. If the stapedius muscle is not 
completely divided as the initial step, the stapes, after disarti- 
culation, is frequently pulled out of sight behind the margin of 
the tympanic ring. After division of the stapedius, disarticu- 
lation by the method usually recommended may dislocate the 
stapes, although this is not likely to occur. It is often diffi- 
cult, however, to insert the knife between the tympanic ring 
and the long arm of the incus, and for this reason I prefer the 
method given in my description of the technique of the pro- 
cedure — that is, to pass the angular knife in front of the long 
arm of the incus and open the articulation by cutting down- 
ward and backward against the pull of the tensor tympani. or 
to open the joint at its lower aspect, and then to sweep the 
knife through it by carrying it backward and forward. By 
either of these methods the joint is more easily opened than 
when an attempt is made to carry the angular blade behind 
the long process of the incus, which frequentlv lies so close to 
the tympanic margin that considerable violence must be used 
in introducing the knife. 

In removing the incus Kretschmann." who was the first to 
formulate the procedure for removing this ossicle, made use 
of a hook which, in addition to the curve shown in Fig. 125 j k, 
was bent outward at the distal extremitv so that when the in- 
strument was in position the tip rested upon that small shelf- 

* Arch, fur Ohrenheilk., vol. xxv, p. 165. 



CARIES OF THE INCUS. 523 

like structure of the superior wall of the canal which affords 
lodgment for the incus. He introduced the instrument with 
the concavity directed backward, and brought the incus into 
view by rotation backward and traction downward. While 
this manipulation is no doubt of great value in certain cases, 
the backward rotation seems more likely to carry the ossi- 
cle far out of reach toward the mastoid antrum in case it is 
not secured at once, and the manipulation of attempting to 
bring the long process into view by passing a hook behind it 
and rotating forward has in my hands proved very satisfac- 
tory, while it certainly lessens the danger of displacing the 
ossicle far backward. 

The teaching that it is not advisable to make a prolonged 
search for the incus seems to me unwise. In nonsuppurative 
cases careful manipulation will render failure to secure it ex- 
ceedingly rare. If it has not been displaced it must occupy 
its original position, and failure to bring the long process into 
the field of vision will render it impossible for the operator to 
be certain of a complete division of the incudo-stapedial articu- 
lation ; or if the head of the stapes is seen lying free in the 
field, it is certain that the incus has been displaced and, by 
acting as a foreign body, may give rise to trouble if allowed 
to remain. If the long process is in view there is no difficulty 
in removing the ossicle. 

In purulent cases it is still more important that the ossicle 
should be removed. Ludewig * found the incus carious in 
eighty-five per cent of the cases upon which ^^ 

he operated. In twenty-nine cases of puru- ^4* w^" 
lent otitis operated upon by the author,f the Fl . G - I4a "7 Caries of 

r r J ' incus. -Long pro- 

ossicle was carious in nineteen, while in eight cess destroyed; 
it had been completely destroyed. Prolonged ^(AutWs 
manipulation in searching for the ossicle has specimen, natural 
not, in my hands, in any way added to the re- 
action following the procedure, nor has it interfered with the 
results. I should therefore earnestly advise prolonging the 
operation for the purpose of securing the incus rather than 
performing a rapid operation and failing in its removal. 

Among the complications which may interfere with the 
operation, haemorrhage is the one upon which special empha- 

* Arch, fur Ohrenheilk., vol. xxix, p. 241 ; vol. xxx. p. 263. 

f Supplement to the Reference Handbook of Medical Sciences, New York. 1893. 



524 



MIDDLE-EAR OPERATIONS. 



sis is laid. Since I have operated with the patient in the semi- 
recumbent position, annoying haemorrhage has been the ex- 
ception rather than the rule. If it is sufficient to interfere 
with the manipulation, it can always be checked by tampon- 
ing the canal firmly with cotton pledgets. It is important in 
executing this manoeuvre that the first pledget should be car- 
ried well into the tympanic cavity, and also that the pledgets 
should not be too large, as the removal of a large tampon is 
likely to lead to a recurrence of the haemorrhage. This ob- 
jection is overcome if a number of small plugs are used in- 
stead of a few large ones. It may be necessary to repeat the 
tamponing several times, but it will certainly effect its pur- 
pose if a little patience is exercised. In place of the cotton 
pledgets, a strip of sterile gauze may be used. This is more 
easiiv removed than the cotton tampons, and is equally effi- 
cient. It has recently been my practice to moisten the strip 
of gauze with the sterilized suprarenal solution already men- 
tioned. The haemostatic action of this preparation materially 
increases the efficiency of the tampon. Schmiegelow * has re- 
ported one case in which the haemorrhage was so severe that 
he was obliged to discontinue an attempt to excise the malleus. 

My own experience with intratympanic operations, more 
especially the particular class now under discussion, has led me 
to consider them remarkably free from risk. It is possible. 
however, for unpleasant sequelae to follow such procedures. 
Among these the most important are injury to the facial nerve, 
deafness from accidental impaction of the stapes into the oval 
window, injury to the labyrinth from accidental or intentional 
removal of the stapes, either bv direct traumatism or bv in- 
fection, etc.. and inflammation of the mastoid process. 

The facial nerve is occasionally injured bv the incus hook. 
The cause of this accident is to be found either in a congenital 
defect in the Fallopian canal or in the partial or complete de- 
struction of its walls as the result of disease. With the exer- 
cise of a little care in manipulating the incus hook, bearing in 
mind that great force is not necessary to displace the ossicle. 
the accident can usually be avoided. If the facial nerve is 
touched by the instrument the twitching of the face immedi- 
ately warns the operator of what has occurred, and subse- 
quent caution will prevent serious injury. In one of my own 
cases twitching of the face was noticed while attempting to 



Hospitals riir::ie. 3. R. V.. Xos. 



STACKE'S OPERATION. 525 

locate the incus, and upon recovery from anaesthesia there was 
marked paresis of the corresponding side of the face; the fa- 
cial nerve had been slightly involved before the operation, but 
after this the signs were much more pronounced. The paraly- 
sis disappeared under the use of the faradic current. Facial 
paralysis consecutive to a similar operation occurred also in a 
case reported by Ludewig.* 

In view of the fact that all portions of the tympanic cavity 
are not accessible through the canal, and in order that the pro- 
cedure may be more directly under the eye of the operator, 
Stacke f prefers to expose the parts by external incision. His 
method is as follows: An incision is made down to the bone 
just behind the attachment of the auricle, and, following this 
in direction, is continued from the tip of the mastoid process 
to a point just above the tragus. With a small elevator the 
cartilaginous meatus and as much as possible of the periosteum 
of the osseous canal are separated from the bony parts. In 
this manner the superior, posterior, and inferior aspects of the 
margin of the bony meatus are exposed. The soft parts are 
now divided transversely downward and forward as deeply in 
the canal as possible, and by traction upon the auricle the funnel- 
like mass is pulled out of the bony meatus (Fig. 150). The 
periosteum of the anterior wall is next divided, when the entire 
cartilaginous meatus and a part of the thin cutaneous lining 
of the osseous canal may by traction forward be so displaced 
as to leave the margin of the bony meatus entirely free. The 
tympanic structures may then be seen by direct light and all 
affected parts, including the carious ossicles, are removed. By 
means of the gouge the superior and posterior margins of the 
inner extremity of the bony meatus may now be removed, and 
the stapes being protected by a proper instrument, the curette 
may be freely used in the vault of the tympanum, the manipu- 
lations being under ocular inspection. In this manner the en- 
tire cavity may be cleared completely of necrotic tissue and the 
mastoid antrum even may be exposed. In case there is evi- 
dence of serious mastoid involvement the original incision is 
made a little farther back than directed and the antrum entered 
in the ordinary way, after which the tympanic cavity is exposed 
and treated in the manner described, and finally the canal and 

* Arch, fiir Ohrenheilk., vol. xxix, p. 259. 

f Ibid., vol. xxxi, p. 201. Freilegung der MittelohrraUme. Tubingen, 1897. 



526 



MIDDLE-EAR OPERATIONS. 



the artificial opening into the antrum are thrown into one. In 
this way the middle ear, mastoid cells and canal are converted 
into a single cavity, all parts of which are easily accessible 
through the external meatus. 

After the operation the cartilaginous canal is replaced and 
a drainage tube is passed into the bony meatus, completely fill- 
ing its lumen, and thus preventing displacement of the soft parts. 
Instead of the drainage tube it is quite sufficient to pack the 
meatus firmly by means of iodoform gauze, the gauze being 
carried well into the tympanic cavity and applied firmly enough 
to crowd the soft parts upward and outward against the bony 
wall of the canal. Contrary to the directions given by Stacke. 
I do not consider it necessary to carry the transverse incision 
through the anterior canal wall. It is quite sufficient to incise 
the superior, posterior, and inferior walls of the fibro-cartilagi- 
nous tube, after separating the soft parts from the bony struc- 
tures to which they are attached. A better view of the deeper 
parts may be gained if before retracting the anterior flap a hori- 
zontal incision be made along the middle of the posterior wall of 
the fibro-cartilaginous canal, this incision extending from the 
point where the canal is divided transversely, to a point just 
within the concha. If, now, a strip of gauze is introduced 
through the external auditory canal and brought out at the 
external opening, firm traction on this gauze strip will draw the 
entire anterior flap forward, and enable the operator to see the 
fundus of the canal very clearly. The external incision is 
sutured, all drainage being through the meatus. In cases where 
the mastoid antrum has been freely exposed it is usual to incise 
the soft parts of the canal longitudinally along the posterior 
aspect and press the flaps thus formed backward into the cavity, 
holding them in position with tampons of iodoform gauze. In 
this manner a cutaneous lining for the mastoid antrum is 
secured. The same result is attained by cutting a quadrilateral 
flap from the cutaneous canal and carrying it into the antrum. 

From a careful study of the Stacke operation, I am not yet 
convinced of its value. My own experience in the treatment 
of mild cases of middle-ear suppuration by the removal of the 
ossicles through the canal, the removal of the floor of the tym- 
panic attic by means of the rongeur forceps, and the thorough 
curettement of the entire tympanic cavity, including the vault. 
has led me to believe that where the disease is confined to the 
middle ear alone, this method of procedure is eminently satis- 



REMOVAL OF THE STAPES. 



527 



factory. Out of ninety-two cases upon which I have operated 
by removing the ossicles and curetting the tympanic cavity, 
fifty-three were cured, twenty-five improved, two unimproved, 
.and in twelve the result was unknown. Schroeder * reports 
one hundred and thirty cases of extraction of malleus and 
incus for middle-ear suppuration. Out of this number sixty- 
two were cured, thirty-nine were not cured, and in twenty- 
eight the result was unknown. 

I confess that by personal experience this operation has 
been limited to a few cases. These possibly may not have been 
well selected, although considerable care was exercised in their 
selection. My own belief is that where a posterior incision is 
necessary, in order to remove carious bone from the tympanum, 
the operator should not be content to expose the tympanic vault 
and aditus ad antrum alone, as these parts can be equally well 
exposed through the natural channel. When, therefore, any 
doubt exists as to the extent of the suppurative process, it has 
always been my practice to do the complete Stacke-Schwartze 
■operation — that is, to enter the mastoid antrum in the usual 
way, and to throw this cell and the vault of the tympanum into 
one large cavity communicating directly with the external mea- 
tus. This operation is fully described on a subsequent page, 
under the head of the Stacke-Schwartze Operation. 

Stapedectomy. — (a) When the membrana tympani is intact. 
The incudo-stapedial articulation is exposed either by a curved 
incision in the postero-superior quadrant close to the attach- 
ment of the membrane to the tympanic ring, or by a triangu- 
lar incision in this situation, or by the incision already de- 
scribed in the operation of exploratory myringotomy. After 
the incudo-stapedial articulation is brought into view the sta- 
pedius muscle should be completely divided; the incudo- 
stapedial articulation is then severed and the long arm of the 
incus pushed forward so as not to interfere with the subse- 
quent steps. If the presence of the incus still interferes with 
the separation of the stapes the long process may be seized 
with the forceps and the ossicle removed. The stapes is then 
freed, by means of the sharp straight knife, from adhesions 
binding it to the oval niche, and is removed by gentle traction 
with t*he forceps or by a hook passed between the crura. It is 
important to sever the stapedius muscle completely before dis- 

* Arcbiv fiir Ohrenheilkunde, vol. xlix, p. 17. 



528 



MIDDLE-EAR OPERATIONS. 



articulation, as otherwise, after separation from the incus, the 
stapes may be pulled out of view. If the foot plate is found 
anchylosed this condition may be treated in the manner 
already suggested, although in such a case, as the parts would 
be subjected to more violence, it is probable that removal of 
the malleus, incus, and membrana tympani would diminish the 
chances of reaction after the operation. 

After the first incision through the membrana tympani, the 
direct application of the cocaine solution to the middle ear by 
means of a cotton-tipped probe renders the subsequent steps 
painless. In three cases of this kind I have been able to clear 
the oval niche in the above manner, no pain being experienced 
after the first incision through the membrana. If a very sharp 
knife is used this is never severe. After this no pain need be 
felt if cocaine is carefully applied. My results have been fairly 
satisfactory; but I am inclined at present to confine the pro- 
cedure to cases where the condition has resulted from a suppu- 
rative inflammation, and in non-suppurative cases to mobilize 
the stapes instead of removing it. In these cases, if mobiliza- 
tion improves the hearing, I also prefer to remove the malleus, 
and incus, thus leaving the stapes accessible in case a second 
mobilization becomes necessary. 

After removal of the stapes the flap may be replaced and 
held in position by a paper dressing. The meatus is occluded 
by a plug of antiseptic cotton, which is left in position for 
several days unless inflammatory symptoms supervene. The 
wound usually heals in a few days, and in no case has the 
reaction been severe. 

(b) When the membrane is partially destroyed the stapes or 
the incudo-stapedial articulation may be already in view; but 
if neither is visible, the appropriate incision for the exposure 
of these parts will vary in each case, after which the technique 
previously given is to be carried out. In two cases operated 
upon under local anaesthesia, the stapes being clearly in view, 
extraction was easily accomplished and the results were flatter- 
ing, in one instance the hearing for a low whisper increasing 
from seven to thirty feet. Here the entire stapes was removed 
intact. In the second case only a portion of the ossicle was 
secured and removed, yet the improvement was considerable. 
It is well to bear in mind that even slight haemorrhage will render 
the removal of the stapes difficult; and when this region is. 
covered by dense structures, which bleed freely when incised,. 



STATISTICS OF AUTHOR'S OPERATIONS. 



529 



it may be necessary to remove the malleus and incus and 
remains of the membrane to secure a suitable field for the 
performance of stapedectomy. 

The after-treatment may be the same as in the preceding* 
class of cases. It is well, however, to inspect the ear at the 
end of twenty-four hours, and, if signs of inflammation are 
present, to cleanse it frequently with a mild antiseptic solu- 
tion. If, however, the parts are perfectly dry, they should 
not be disturbed, for fear of interfering with the healing 
process. 

From personal experience, the author believes that at the 
present time a lesion of the conducting mechanism resulting 
from a non-suppurative inflammation which demands operative 
interference will be more satisfactorily combated by the removal 
of the membrana tympani, malleus, and incus, and mobilization 
of the stapes, than by other operative measures. In residual 
purulent cases mobilization of the stapes will usually yield re- 
sults as good as those obtained by stapedectomy. The ad- 
vantage of removing the two larger ossicles in both classes 
of cases lies in the fact that the stapes is thus left exposed, and 
can be repeatedly mobilized if necessary. When the ossicle is 
mobilized or removed, and the flap of drum membrane is allowed 
to resume its former position, the beneficial results are often 
but temporary, and disappear when the opening in the mem- 
brana closes. 

When operations are performed for improvement of func- 
tion they may always be conducted under local anaesthesia, 
and the improvement or failure to improve may be noted at 
each successive step. The operation can therefore be discon- 
tinued at any stage, if the operator judges that he is not war- 
ranted in proceeding. 

The results of my operations were reported * a few years 
since, and the compilation which follows includes a few addi- 
tional cases. 

Of cases where the membrana tympani was intact, includ- 
ing one or two instances where there had been a suppurative 
process in childhood, with complete closure of the perforation, 
ninety have been subjected to operation. Of these, there was 
much improvement in seventy-eight cases, ten were unim- 
proved, one grew worse after the operation, and in one the re- 

* Transactions of the American Otological Society, 1894. 



,530 MIDDLE-EAR OPERATIONS. 

suit was unknown. Thirteen of these cases were operated upon 
under ether. Of these, two were greatly improved, five much 
improved, five slightly improved, and in the remaining case 
the condition remained the same as before operation. 

In eleven cases the condition was due to a previous purulent 
inflammation, which had resulted either in a slight or extensive 
destruction of the membrana tympani, the perforation persist- 
ing. The operative procedures were confined to freeing the 
stapes and mobilizing it, as described in the preceding pages, 
without resort to general anaesthesia. Of these, there was 
great improvement in one, the whispering distance increasing 
from twelve inches before to fifteen feet after operation, and 
the degree of improvement being maintained at the time of the 
last examination, which was about six weeks after operation. 
In ten there was decided improvement, although not as great 
as in the case, just mentioned. Of the eleven cases, disagree- 
able symptoms followed the operation in but one instance. 

In ten cases there was a purulent otitis, in which the opera- 
tion was performed both for the relief of the otorrhcea and at 
the same time to improve the hearing. Of these, there was 
great improvement in five, moderate improvement in three, 
while in two the function of the organ remained the same as 
before operation. 

In ten cases the membrana was intact and the stapes was 
removed, or the crura fractured in the attempt at removal, the 
operation being done with cocaine. In most instances removal 
of the incus was necessary in order to gain access to the stapes. 
Of the ten cases, three were improved, two were much im- 
proved, one slightly improved, two unimproved, and two were 
made worse. In one case, where much improvement followed 
the operation, a relapse took place at a later period, although the 
hearing still remained better than before the operation. 

In quite a number of these cases of stapedectomy it was 
found that the improvement became much less after the per- 
foration in the membrana tympani closed, and in these instances 
the malleus and membrana tympani were removed at a later 
period, in order to secure a permanent opening into the tym- 
panic cavity. This procedure was followed by improvement in 
all the cases. In one instance synechiotomy was practiced for 
the improvement of hearing before the purulent discharge had 
•ceased entirely, this being so moderate in amount as scarcely 
to warrant general anaesthesia and the removal of the entire 



STATISTICS OF AUTHOR'S OPERATIONS. 531 

ossicular chain. Slight improvement followed the procedure in 
this instance. 

It will be seen from these statistics that the greatest im- 
provement has followed those operations performed under 
cocaine anaesthesia, and where the design has been to secure a 
permanent opening into the tympanum. This seems to be the 
most rational procedure in all cases where the membrana tym- 
pani is intact; and since it can be done without general anaes- 
thesia, we are certainly warranted in recommending at least 
an exploratory tympanotomy in all cases where the hearing has 
failed to improve under less radical measures. In no given case 
can we state the amount of improvement which we should ex- 
pect, and it is always our duty to inform the patient of the experi- 
mental character of the measure. From the fact, however, that 
the procedure is followed by no discomfort, that it can be per- 
formed without pain, and that, humanly speaking, it will not 
injure the organ, we certainly fail to fulfill our entire duty to 
the patients if the subject is not presented to them fairly. 



CHAPTER XXVIII. 

THE MASTOID OPERATION. 

The instruments required for this operation are shown in 
Plate XII. While all of these instruments may not be neces- 
sary in each case, experience teaches that the more complete 
the armamentarium, the better and more rapidly can the work 
be accomplished. 

The ear should be first thoroughly cleansed by syringing 
with i-to-1,000 bichloride solution, or with a dilute (i to 10) 
solution of peroxide of hydrogen, after which the meatus is 
thoroughly tamponed with iodoform gauze. The scalp should 
be shaved over an area extending in every direction for a dis- 
tance of three inches from the meatus, and if the patient has a 
beard it should also be removed. The skin is then scrubbed, 
first with soap and water and then with ether and alcohol, and 
finally with a solution of bichloride of mercury (i to 1,000), or a 
two-and-a-half-per-cent solution of carbolic acid. A wet bichlo- 
ride dressing is then applied over the entire field of operation 
and allowed to remain until the patient is anaesthetized. When 
possible, this preparation of the field should be made at least 
four or five hours before the time of operation. 

After the induction of anaesthesia the antiseptic dressing is 
removed, the tampon within the canal is changed, and the in- 
tegument washed again with ether, and irrigated subsequently 
with a bichloride solution (i to 2,000). The parts immediately 
surrounding the field should be covered with towels moistened 
in i-to-1,000 bichloride solution. All instruments are to be 
sterilized by boiling, and the hands of the operator and his 
assistants should receive the ordinary attention demanded in 
all surgical operations. 

It may seem unnecessary to take all these precautions in a 
procedure apparently so simple; but when we remember that, 
owing to an anomalous position of the parts, or to the destruc- 
tion resulting from the inflammation, we may either enter the 

(532) 



PLATE XI. 





The Mastoid Operation. 



DIVISION OF SOFT PARTS. 533 

cranial cavity accidentally or feel compelled to do so as a matter 
of election, we should never undertake the procedure without 
being thoroughly prepared to extend our operation in this direc- 
tion if necessary. The primary incision begins over the middle 
of the mastoid insertion of the sterno-cleido-mastoid muscle, 
about half an inch below the tip of the mastoid process, and 
is carried upward and forward close to the line of insertion of 
the auricle, after which it follows this line to a point directly 
about the meatus (See Plate XI). 

Particular attention should be given to the location of 
this incision, as ordinarily the line of section lies so far back 
that when the flaps are retracted the posterior and superior 
walls of the canal are not freely exposed. In addition to this, 
the free vascular supply of anterior flap causes it to become 
cedematous almost immediately, thus increasing the difficulty 
with which it is drawn forward, rendering a perfect exposure 
of the parts impossible. If the line of incision is made so close 
to the auricular insertion as to admit of the introduction of a 
line of sutures only, the field of operation will be much better 
exposed, while subsequent deformity will be prevented, the 
cicatrix being concealed completely by the auricle, which 
resumes an absolutely normal position. The soft parts 
should be divided to the bone throughout the entire extent 
of the incision. All bleeding points should be secured with 
clamps. 

The next step of the operation is elevating the periosteum. 
The entire anterior flap is pushed forward by means of an 
elevator carried beneath the periosteum, raising this and the 
overlying muscular structures from the bone, the parts being 
pushed forward until the posterior and superior margins of 
the bony canal are plainly in view. The posterior flap is ele- 
vated in a similar manner. All bleeding points are now caught 
by means of clamps. The auricle is held forward by a retrac- 
tor, the instrument being intrusted to the hands of the assist- 
ant. The upper part of the incision is filled with gauze 
sponges, in order that all oozing may be controlled, while 
the operator directs his attention to clearing the aponeurosis 
of the sterno-mastoid muscle from the tip of the process. 

This is best clone with blunt scissors curved on the flat, 
which can be closely applied to the bony surface and made 
to divide the dense fibrous tissue by successive short cuts. 
Care must be taken to hug the bone closely, otherwise the 



534 



THE MASTOID OPERATION. 



large vessels of the neck may be injured. This separation of 
the muscle should be continued until the ringer can be passed 
completely around the tip of the mastoid, and if the primary 
incision has not been made low enough to allow this, it must 
be extended. The packing is now removed from the upper 
part of the wound and the exposed area is examined for the 
presence of any sinus, the result of spontaneous rupture. If 
this is found, it is enlarged either by the curette or gouge, the 
surgeon following the channel which has been thus established, 
and which will be found in all cases to communicate either 
directly or indirectly with the mastoid antrum. If no sinus is 
present, the first step in every case is to enter the antrum. We 
remember the location of this to be just behind the posterior 
margin of the meatus and just below its superior margin. Until 
we have gained entrance to this cavity our opening through the 
cortex should never extend above the superior wall of the canal, 
thus avoiding the middle cranial fossa, while we should keep 
close to the posterior wall on account of a possible malposition 
of the lateral sinus. 

The cortex is best removed by means of the chisel or gouge 
(Plate XII, P and Q) and mallet, a large cutting instrument 
being used at first and changed for a smaller one as the wound 
is deepened. The chisel is applied nearly parallel to the sur- 
face of the skull, and made to cut away the bone in thin, broad 
chips, the cutting edge being directed downward and forward. 
In this way we form a bony funnel, the base of which may be 
broadened posteriorly and below, if necessary, but never above. 
The apex of the cone should always lie within the triangle which 
marks the entrance to the antrum. Where the pneumatic spaces 
are superficial they may be opened with the first blow of the: 
mallet, after which it is wise to lay aside the chisel and con- 
tinue the operation by means of the sharp spoon (Plate XII,. 
O), breaking clown the walls of the air spaces until the mastoid 
antrum is entered. This never lies less than half an inch below 
the surface, although we may encounter large pneumatic spaces 
more superficially. We recognize that the antrum is entered by 
the fact that a probe, slightly curved at the tip, after entering 
the artificial opening, passes downward, forward, and inward for 
a distance of from three quarters to seven eighths of an inch, 
at which depth it enters a cavity of considerable size; in other- 
words, it has passed into the middle ear. We persist in our 
efforts at entering this cavity, although pus may have been 



PLATE XII 




Instruments for Mastoid Operation. 

A, B, C, D, E, Rongeur forceps, various sizes ; F, G, retractors ; H, mallet ; I, 
dissecting forceps ; J, probe and director ; K, needles, silk, and catgut ; L, needle- 
holder ; M, scalpels ; N, artery clamps ; O, sharp spoons ; P, straight chisels ; Q, 
gouges ; R, periosteum elevators ; S, straight scissors, curved and flat. 



REMOVAL OF SOFTENED BONE. 535 

evacuated previously. The passage between the antrum and 
the tympanum should next be curetted freely by means of a 
delicate sharp spoon (Fig. 123, a). This portion of the tract is 
invariably occluded by granulation tissue, while its bony walls 
are often carious. 

The next step is to thoroughly obliterate the entire pneu- 
matic structure of the mastoid process. The remaining cortex 
is removed with the chisel, curette, or rongeur, as may be 
most convenient. The large cell at the apex must be particu- 
larly investigated, opened freely, and the tip of the mastoid 
process should be removed with the rongeur forceps. The 
operation should be continued until sound bone is encountered 
in every direction. In some cases, the destruction of bone will 
be found to be so extensive as to prevent the removal of all dis- 
eased tissue through the single linear incision already advised. 
A second incision is then made from the middle of the linear 
incision, extending horizontally backward for a distance of one 
inch to an inch and a half. The bleeding points are secured by 
means of clamps and the underlying bone is uncovered by 
means of the periosteum elevator. The mastoid emissary vein 
may be wounded in elevating the periosteum, and quite free 
haemorrhage occur. This haemorrhage is easily controlled by 
means of a folded strip of iodoform gauze placed over the vessel. 
This is held in position by an assistant, while the operator pro- 
ceeds to remove all softened bone. If the inner table is affected, 
we should not hesitate to remove it, as an exposure of the dura 
under proper precautions is a matter of no importance, while 
to leave carious bone in contact with this, is a grave error. Ex- 
posure of the lateral sinus, either accidentally or intentionally. 
in no way complicates the operation. If the vessel is opened, 
sharp haemorrhage results, and herein lies the advantage of 
extensively removing the cortex. If the wounded vessel lies at 
the bottom of a deep, narrow, bony channel, the haemorrhage 
may be controlled; but it is difficult to proceed with the opera- 
tion, and the purpose for which it was instituted will therefore 
not be carried out. With a free removal of the cortex the 
bleeding point lies plainly in view, and the haemorrhage is 
easily controlled by a firm compress of iodoform gauze. This 
is held by an assistant, and the surgeon finishes the operation 
as though nothing untoward had happened. Haemorrhage from 
the sinus is no more severe than that from one of the large 
venous trunks of the upper extremity, and the possible untoward 



536 THE MASTOID OPERATION. 

results which may follow a wound of this vessel will depend 
upon the imperfect exposure of the bleeding point rather than 
upon the loss of blood or the accidental infection through the 
sinus. 

Having now removed all softened bone, the wound may or 
may not be irrigated, according to the individual choice of the 
surgeon. I am inclined to favor dry cleansing. All bleeding 
points are then secured with catgut ligatures. The bony cavity 
is packed loosely with iodoform gauze, the tampon in the canal 
is reapplied, and the soft parts are allowed to fall back over 
the opening in the bone, their edges being separated by a 
narrow strip of gauze only. If it has been necessary to make 
the posterior horizontal incision, this should be closed by means 
of silkworm-gut sutures. In cases where the mastoid emissary 
vein has been wounded and there has been considerable haemor- 
rhage, a small pledget of gauze may be placed over the foramen 
through which the vein passes, the end brought into the mas- 
toid wound, and the horizontal incision sutured over this 
packing. It is not necessary to pack the external wound, as 
was formerly done, and the omission certainly renders the first 
dressing more comfortable. The dressing is completed by 
covering both the wound and the ear with several layers of dry 
sterilized gauze and cotton, the whole being confined in place 
by a bandage. 

In cases where the lateral sinus has either been exposed or 
wounded, or where the dura in the middle cranial fossa has been 
exposed, these areas should be isolated from the remainder of 
the mastoid wound by a separate gauze packing. My own 
procedure in these cases is as follows: After all softened bone 
has been removed, a strip of iodoform gauze is carried through 
the aditus ad antrum as far toward the middle ear as possible. 
The gauze is packed in firmly until the aditus and the interior 
of the antrum is rilled. The strip of gauze is then intrusted to 
an assistant and a second strip is packed over the exposed lateral 
sinus, so as to wall this off from the remainder of the operation 
cavity. Any exposed dural area is treated in a similar manner. 
The strip of gauze, one end of which has been carried into the 
antrum, is now packed into the mastoid cavity, and those strips 
of gauze which have been used to isolate the sinus and exposed 
dura from the remainder of the wound are subsequently packed 
in about this. In this manner, we wall off, so to speak, the 
cranial cavity from the remainder of the wound and from 



AFTER-TREATMENT OF WOUND. 537 

that part of the wound which is infected, by a firm layer of 
iodoform gauze. I believe that, in many instances, this 
method of dressing the case at the time of operation has pre- 
vented the subsequent involvement either of the meninges or 
of the sinus. 

In cases where the technique has been perfect it is not 
necessary to remove the dressing under five or six days. The 
necessity of changing the dressing at an early period will be 
indicated by a rise in temperature or by local pain. Where 
the temperature does not exceed 101 at any time during the 
first five days, or, if elevated, is not persistent, the dressing need 
not be changed. 

The subsequent treatment is simple. At the first dressing 
we frequently find the canal absolutely free from discharge. 
Unless the discharge is profuse, either from the canal or from 
the wound, irrigation is not to be employed at the subsequent 
dressings. If considerable secretion is present it is wise to 
irrigate the parts freely, the fluid employed being introduced 
through the artificial opening and allowed to pass out of the 
meatus; the technique of the dressing is the same as at the 
time of operation. Where the lateral sinus has been opened, 
or the dura exposed in any other location, particular care is 
necessary at each dressing to guard against local infection, the 
exposed dural area being uncovered first, cleansed and protected 
with a gauze pad, after which the packing may be removed from 
the mastoid portion of the wound and the dressing done as above 
directed. 

After the first dressing it will be usually necessary to dress 
the case at intervals of from one to three days. As the wound 
heals, exuberant granulations may appear, and these must be 
treated in the ordinary manner. If the granulations proliferate 
too rapidly, it will be wise to dress the wound with sterile gauze 
instead of iodoform gauze. If this change in dressing does not 
control the granulations, it is wise to cut down the exuberant 
tissue by means of scissors and then touch the cut surface with a 
solid stick of nitrate of silver. Where the destruction of bone 
has been very extensive, we sometimes find that the opening in 
the bone fills up very slowly. Here stimulation of the granu- 
lating surface with nitrate of silver will hasten the reparative 
process. Where the granulations are very sluggish, instead of 
packing the wound over with plain gauze or iodoform gauze, 
the use of sterile balsam Peru gauze will frequentlv cause the 
36 



533 



THE MASTOID OPERATION. 



wound to heal more rapidly. In some of these cases, where 
the reparative process is extremely slow, the mere scraping 
of the granulations with a dull curette, allowing the bony 
cavity to fill with blood, and then applying a sterile gauze 
dressing, has been found efficacious in hastening the healing 
of the wound. 

These suggestions may be of value in the after-treatment. 
Each individual case, however, must be managed according to 
the indications, and suggestions as to the conduct of the after- 
treatment must be followed only in the most general way. 

In addition to wounding the sinus, the operator may oc- 
casionally expose or even wound the dura in the middle cranial 
fossa. Entering the cranial cavity at this point can be avoided 
in every instance if the cortex is not removed above the level 
of the superior wall of the canal. When the temporal ridge is 
very prominent and the margin of the meatus is placed so far 
below this as to render adherence to this rule almost impossible, 
the operator may deem it wise to extend the opening in the 
bone slightly above the line indicated. If the calvarium is unu- 
sually thin, even the most careful may enter the cranial cavity. 
It will seldom happen that the dura is wounded if care is taken 
to remove the bone in successive thin lamellae, and its exposure 
does no harm. It is only necessary to disinfect the parts by 
means of i-to-5,000 bichloride solution, or with a dry sterile 
sponge, after which the opening is covered by a pad of gauze; 
this is intrusted to an assistant, and the operation completed 
in the ordinary manner. Where the dura is wounded, the open- 
ing in the bone should be enlarged; and if the membrane has 
been perforated, it may be wise to enlarge this opening so as to 
thoroughly cleanse the underlying parts. After this the dural 
opening is closed with a fine gut suture and treated in the man- 
ner above described. With a careful operator such an accident is 
absolutely harmless, and in no way complicates the progress 
of the case. In the majority of instances a prominent temporal 
ridge means either a sinus situated farther forward than normal, 
or a low middle cranial fossa, and the surgeon will be particu- 
larly careful to confine himself to the limits of safety when these 
anatomical features present. 

Because the squamous plate of the temporal bone is more 
horizontal in infancy than in adult life, and because of the man- 
ner in which the fibrous canal is applied to the outer surface of 
the squama on account of the absence of the bony canal at births 



POSSIBLE DIFFICULTIES. 539 

attention should be given to certain variations which must be 
practiced when the mastoid of a very young child is to be 
operated upon. At birth, since the fibro-cartilaginous meatus 
along its superior aspect is applied to the external surface of the 
squama, the line of attachment of the auricle to the skull lies 
at a much higher level than does the membrana tympani, and 
the superior extremity of an incision along the line of auricular 
attachment would lie at a much higher level than the upper 
border of the tympanic ring (Fig. 122). The relative position of 
the parts at the line of auricular attachment is misleading, since, 
when the anterior flap is pulled forward, the fibro-cartilaginous 
tube constituting the meatus is attached so firmly above and 
behind as to frequently mislead the operator and cause him to 
think that the margin of the annulus has been exposed. If the 
bone is perforated without exposing the posterior limb of the 
annulus clearly, and making out the exact situation of the 
prominent posterior tubercle, both by touch and by inspection, 
the operator may accidentally open the middle cranial fossa in- 
stead of the pneumatic space of the mastoid and middle ear. 
The superior and posterior attachments of the meatus should 
be separated carefully from the squama after the primary inci- 
sion until the posterior tympanic tubercle is reached and the 
canal merges into the drum membrane. It is often well to 
incise the fibrous tube transversely for a short distance, in order 
that a clear view may be obtained of the membrana tympani 
and render an error impossible. If the bony cavity is entered 
just behind this tubercle and close to it, the antrum will be 
opened, after which it will be easy to chip away the external 
table for a considerable distance forward and upward, thus ex- 
posing the tympanic vault (Fig. 122). It is wise, however, to 
make it a rule to never remove the outer layer of bone at a 
higher level than the posterior tympanic tubercle as a primary 
procedure. The depth of the middle cranial fossa varies con- 
siderably in different subjects, but always lies above the point 
named. The exact conformation of the parts in any individual 
case is easily made out when access is once gained to the pneu- 
matic spaces, after which the operator will adapt his operation 
to the anatomical conditions present. The external wall of 
the tympanic vault at birth occupies in reality the position of its 
inferior wall in adult life, owing to the change in direction 
taken by the squamous plate as development progresses. The 
vault will therefore be entered with very little trouble close 



54 o THE MASTOID OPERATION. 

above the line of attachment of the membrana superiorly. An- 
other word of caution is also proper regarding the initial inci- 
sion. Since the mastoid squamous suture is not ossified at 
birth, and frequently presents large dehiscences filled by fibro- 
cartilage, the knife, in making the initial incision, should not be 
pressed with any force upon the bone, but the soft parts should 
be divided slowly until the bone is exposed throughout the line 
of incision. Firm pressure upon the scalpel might easily result 
in plunging it into one of these dehiscences, causing it to enter 
the cranial cavity. The utmost gentleness should also be ob- 
served in dissecting up the periosteum and turning the ante- 
rior flap forward, for the same reason. 

In every instance, then, either in adults or in children, no 
procedure should be instituted for the removal of osseous tissue 
until the posterior and superior margins of the bony canal are 
not only accessible to the finger but plainly in view, and the 
soft parts should be so retracted that the landmarks may be 
always under the eye of the surgeon throughout the entire 
operation. 

The facial nerve as it crosses the tympanic cavity is occa- 
sionally wounded in cases of sclerosis where the bone has been 
removed to a sufficient depth to expose the internal wall of the 
middle ear. The aquaeductus Fallopii lies within the middle 
ear, and consequently it is impossible to wound it until the 
operation is really completed and free communication estab- 
lished with the tympanum. It is wise, after perforating the bone 
to a depth of seven eighths of an inch, or perhaps a little less, 
to pass a probe bent at a right angle into the external auditory 
meatus, and carry the angular portion upward and backward 
into the tympanic vault, in which position it is to be held. The 
operator then has only to continue the removal of bone until 
the artificial opening exposes this probe within the tympanum. 
A wound to the external semicircular canal is more unlikely to 
occur than one of the facial nerve. The canal lies immediately 
above the aqueduct, and can only be injured when the opening 
is made exceedingly high. When in any doubt as to the advis- 
ability of perforating more deeply on account of the possibility 
of injuring either of these structures, the plan usually followed is 
to remove that portion of the posterior wall of the canal lying 
immediately in front of the artificial opening. The canal must 
lead into the middle ear, and the removal of this bony partition 
until the tympanum is reached renders the completion of the 



TRAUTMANN'S OPERATION. 



541 



procedure absolutely safe. In these cases that portion of the 
bony posterior wall at the inner extremity of the canal, made 
up of compact osseous tissue, should be left, since it is possible 
to wound the facial nerve under these conditions if the entire 
posterior wall is removed. Slight injury to the facial nerve is 
not a serious accident, function being restored in from three to 
five weeks, in most cases, under the use of the faradic current. 

In certain cases where the destruction of the osseous tissues 
has been very extensive, and where during the period of con- 
valescence sequestra separate from the bony walls, a perma- 
nent opening will remain behind the ear. This has occurred 





Fig. 141. — Plastic operation for closure Fig. 142. — The same operation, showing 
of opening behind the ear, as advised manner of passing sutures, 

by Trautmann. 

six times in over four hundred operations. Various methods 
have been devised for closing these openings, among which 
is one advocated by Trautmann.* This consists in circum- 
scribing the entire opening by means of an incision extend- 
ing simply through the skin. Two semilunar flaps will thus 
be formed, one before and one behind. These two flaps are 
dissected up from over the underlying tissues and turned 
into the opening. Their raw edges are united in the me- 
dian line by means of sutures either of catgut, which will 
easily be absorbed, or bv means of silk sutures, the sutures 



Operationen am Gehororgan, Berlin, 1901, p. So. 



542 



THE MASTOID OPERATION. 




being so passed that when tied the knots will lie within the 
external auditory meatus. The raw surface of these flaps is 

then covered by dissecting up 
the integument anteriorly and 
posteriorly and drawing this 
together over the flaps thus 
formed, the superficial sliding 
flaps being sutured in the me- 
3 dian line, thus covering per- 
fectly the raw surface, and 
5 effectually closing the fistula. 
When the fistula is closed in 
this manner, it will be easily 
seen that the meatus is com- 
pletely lined with epidermis 
throughout, the cutaneous 
surface of the internal flaps 
or those first formed being 
turned into the meatus. The 
opening behind the ear is en- 
tirely obliterated and covered 
by skin owing to the approx- 
imation of the sliding skin flaps which cover completely 
the internal flaps first formed. The only fault to be found 
with this method is that, owing to the fact that the poste- 
rior opening in these cases is lined with cicatricial tissue, 
the nutrition of the flaps is exceedingly poor. The flaps 
are, therefore, very liable to slough, and the operation to 
prove a failure. A more satisfactory method of closing these 
openings is that of Mosetig-Moorhof.* For this method a 
tongue-shaped flap is cut from the integument immediately 
below the opening to be closed. This flap is dissected up from 
below and on the sides, being allowed to remain attached supe- 
riorly to the inferior margin of the perforation to be closed. 
The flap should be considerably larger than the opening which 
it is required to fill in order to allow for subsequent contraction. 
After this flap has been dissected up the margins of the open- 
ing are denuded by means of the scalpel, the skin about the 
margins of the perforation being dissected away from the un- 
derlying tissues behind, above, and in front. The tongue- 



FlG. 143. — Trautmann's operation, show- 
ing deep sutures tied and superficial 
wound closed with interrupted sutures. 



* Centralblatt fur Chirurgie, 1898, No. 46. 



MOSETIG-MOORHOF'S OPERATION. 



543 



shaped flap is then turned into the opening to be closed, and 
held in place by catgut sutures. The integument in front and 
behind the opening into which this flap is turned is then also 
dissected up, the dissection being carried downward along the 
margins of the denuded area from which the flap was taken. 
In this way, two sliding skin flaps are formed, one in front and 
the other behind, which upon being approximated will com- 






l 

2 

ElG. 144. — Mosetig-Moorhof's operation for closure of retro-auricular fistula. No. I, 
/, Tongue-shaped flap cut from tissues of neck ; No. 2 shows this tegumentary 
flap elevated and margins of the retro-auricular opening (0) denuded ; No. 3, /, 
Flap sutured in position ; A, Denuded area left where flap is dissected up ; No. 
4, External wound closed by sutures (h) after undermining edges of wound. This 
undermining should be continued about the fistulous opening as well, so that 
when the superficial wound is sutured, the raw surface of the flap will be com- 
pletely covered by integument. This is not shown in the figure. 

pletely cover the tongue-shaped flap which fills the opening 
behind the ear, as well as the denuded area from which this 
tongue-shaped flap was taken. These sliding flaps are ap- 
proximated and held in position by either silk or silkworm- 
gut sutures. I have employed this method in closing openings 
of this character; although union by first intention may not 
take place throughout the entire extent of the wound on ac- 
count of the fact that the flaps are formed almost entirely 
of cicatricial tissue, the procedure is effectual in completely 
closing the perforation. Although portions of the flap may 
slough, the resulting wound heals readily by granulation, and 
the result of the operation seems to be good in every instance. 
Quite recently Frey * has reported a number of cases in 
which the deformity following an extensive mastoid opera- 
tion has been entirely relieved by the subcutaneous injection 
of paraffin. This method has been used not only to fill up 
the retro-auricular depression, so frequently found in those 



Archiv fur Ohrenheilkunde, vol. lvi. p. 2S9. 



544 THE MASTOID OPERATION. 

cases, but also to actually fill up any permanent opening 
behind the ear, which may have been left as the result of 
the operation. In cases where a post-aural fistula of con- 
siderable size is present, the method consists in making a 
subcutaneous injection into the tissues forming the anterior 
— that is, the auricular margin of the fistula. These tissues 
are exceedingly soft, and a sufficient amount of paraffin can 
be injected into the anterior flap to cause this to cover over 
the post-auricular opening. In this way the cutaneous sur- 
face of the anterior and posterior margins of the fistula are 
brought into close apposition. A few weeks after the tissue 
has been injected, the cutaneous edges of the anterior and 
posterior margins of the hiatus, which are now in apposition, 
are freshened by means of a scalpel or scissors. These two fresh 
surfaces, lying in apposition to one another, soon become 
united, the closure of the fistula is complete and all deformity 
overcome. The mixture to be injected consists of about equal 
parts of the best paraffin and liquid vaseline. The paraffin is 
melted in an ordinary enameled or porcelain casserole and 
liquid vaseline added. After the mixture has been heated for 
about ten minutes, to thoroughly sterilize it, a glass rod is 
dipped into the mixture and a drop of the fluid allowed to 
fall upon the hand. As soon as this drop touches the skin, if 
it becomes of the consistency of a rather thick ointment, the 
amount of solid paraffin and liquid vaseline is in the right 
proportion, and the injection is proceeded with. If. on the 
other hand, as soon as the drop strikes the cutaneous surface it 
becomes solidified, a little more liquid vaseline must be added 
before injection, to make the mixture slightly more fluid; or 
if, when the drop falls upon the hand, it still retains its fluidity, 
the mixture is not quite thick enough for injection, and a little 
more paraffin must be added. Experimentation will enable the 
operator to make the mixture of the right consistency. 

The technique of injection does not differ from that of par- 
affin injection in other parts of the body. An ordinary explor- 
ing syringe, with a metal barrel and with either an asbestos or 
metal piston, should be used, so that the instrument can be 
thoroughly sterilized beforehand. After the syringe and the 
needle, which should not be too large, have been sterilized, the 
syringe is filled with the liquid paraffin, and placed in a bath of 
hot water to keep the mixture liquid until its injection. When 
all is ready, the tip of the syringe is made to pierce the integu- 



INJECTION OF PARAFFIN. 545 

ment either from below upward or from above downward, and 
is carried some little distance subcutaneously. The fluid is grad- 
ually injected by the operator, while an assistant molds the 
parts into proper shape. It is frequently necessary to introduce 
the needle two or three times before the deformity is com- 
pletely overcome. 

This method will certainly be efficient in relieving defor- 
mity of this kind in certain instances. While the plastic opera- 
tions previously described effect a radical cure of the deformity, 
it must be remembered that in some cases the cicatricial tissue 
is so extensive as to rather militate against success. It is in 
just this class of cases that this method is of particular value. 



CHAPTER XXIX. 

RADICAL OPERATION FOR CHRONIC OTORRHCEA. STACKE- 

SCHWARTZE OPERATION. 

In cases of chronic suppuration, where there is evidently 
an involvement of the adjacent pneumatic spaces within the 
mastoid, no operation either upon the middle ear or mastoid 
alone will be sufficient to cause entire cessation of the dis- 
charge from the middle ear, or, in case mastoid symptoms are 
present, to afford complete relief. Furthermore, it must be 
remembered that in cases of chronic suppuration of the middle 
ear, with extension to the mastoid process, there is always 
danger of infection of the adjacent intracranial structures un- 
less the purulent focus is completely eradicated. Those cases 
of suppurative otitis media of long standing, in which there has 
been a deposit of cholesteatomatous material within the tym- 
panic vault and in the mastoid cells, are particularly prone to 
be complicated by an invasion of the intracranial structures. 
For this reason the surgeon should always perform so thorough 
an operation as to remove every possible source of infection 
from the entire middle-ear tract, and secure such thorough 
drainage as to render an extension of the suppurative process 
inward absolutely impossible. 

Operative procedures have been instituted with this end 
in view; in all of these the absolute necessity of free drainage, 
both of the middle ear and mastoid antrum, is recognized. 

Krister was one of the first to establish through and through 
drainage between the mastoid cells and the external auditory 
canal. This procedure, however, simply established a very 
fair drainage between the external canal and the mastoid cells, 
the tympanic vault having apparently been completely over- 
looked by the surgeon. To obviate this defect, Bergmann 
conceived the plan of thoroughly draining the tympanic vault 
by removing its inferior and posterior wall. The operation 

(546) 



PLATE XII 




Instruments for Radical Operation. 

A, Large rongeur forceps ; B, small rongeur forceps ; C, Tansen rongeur forceps 
for enlarging aditus ; D, periosteum elevators ; E, retractors ; F, scalpels ; G, Stacke's 
angular knives ; H, narrow blunt dissector for separating fibrous meatus ; I, mallet ; 
J, grooved director and probe ; K, Riverdin needle ; L, curved needles, silk, silkworm- 
gut and catgut, the latter used both for sutures and ligatures ; M, needle-holder ; N, 
dissecting forceps ; O, burrs for smoothing bony cavity, prior to grafting ; P, large 
and small chisels and gouges ; Q, curved gouges for removal of external wall of attic ; 
R, sharp spoons of various sizes ; S, cotton-holders ; T, blunt scissors, curved and 
straight ; U, artery clamps. 



STACKE-SCHWARTZE OPERATION. 547 

proposed by Bergmann has been somewhat elaborated by 
Stacke,* who has obtained excellent results by this method. 

The combination of the methods of Kuster, Bergmann, and 
Stacke constitutes, with some slight modifications, the operative 
procedure employed at the present time by most otologists in 
dealing with these cases, and is known as the Stacke-Schwartze 
operation. The technique of the procedure is as follows: An 
incision is made extending from just below the tip of the mas- 
toid and following the curvilinear line of auricular insertion 
about one third of an inch behind this line to a point just 
above the superior attachment of the auricle. The incision is 
carried through all of the soft parts down to the bone. In 
making this incision, operators vary as to the distance at which 
it should be placed behind the line of auricular attachment. 
Thus, Ballance f places the incision at least one half of an 
inch behind the posterior auricular fold. This operator also 
carries the first incision through the integument alone, the 
deeper structures being divided more anteriorly. In this way 
the posterior wound is terraced, so to speak, the line of 
division of the deeper tissues being anterior to that of the 
superficial cutaneous tissue. I have employed this incision, 
but find that it possesses no advantages over the more sim- 
ple method of carrying the initial incision through the soft 
parts clown to the bone. It is important in dividing the 
superficial structures, to carry the incision well forward over 
the top of the ear. If this is not done, it is almost im- 
possible to secure a perfect exposure of the superior wall 
of the canal, and it is therefore difficult to thoroughly re- 
move the external wall of the tympanic vault. In carrying 
the incision over the ear, it is not necessary to divide all the 
soft tissues down to the bone. If the skin and superficial fascia 
are divided in this locality, it will be perfectly possible to thor- 
oughly expose the upper wall of the canal by strong traction 
on the flap without dividing the underlying fibres of the tem- 
poral muscle. All bleeding vessels are secured by clamps, care 
being taken to bruise the soft tissues as little as possible. All 
of the soft parts composing the anterior flap are separated from 
the underlying bone by the use of the periosteum elevator. In 
this way the auricle is turned forward and the margins of the 

* Die operative Freilegung der Mittelohrraume, Tubingen, 1S97. 
f Medico-Chirurgical Transactions, vol. lxxxiii. 



548 RADICAL OPERATION FOR CHRONIC OTORRHCEA 

bony meatus become visible. The fibro-cartilaginous lining" 
of the bony meatus is now carefully separated from the osseous 
walls by means of a narrow, blunt-pointed periosteum elevator, 
or, if this instrument is not at hand, the closed blades of the 
blunt-pointed scissors, curved on the flat, may be used for this 
purpose. The fibro-cartilaginous tube is dissected from the 
upper, posterior, and inferior walls to as great a depth as pos- 
sible. In cases of profuse suppuration, of long standing, it 
will be impossible to separate the soft lining of the canal from 
the underlying bony parts for any considerable distance. In 
cases where there has been but slight discharge, however, the 
surgeon can frequently carry this dissection to within a short 
distance of the drum membrane before the lumen of the car- 
tilaginous canal is opened by the instrument. When this dis- 
section has been carried as deeply as is practicable, the fibro- 
cartilaginous tube is divided transversely, as close to the drum 
membrane as possible by means of an angular knife. A strip of 
gauze is then introduced into the external auditory meatus and 
brought out through the opening behind the ear. Firm trac- 
tion is now made on this strip and the entire fibro-cartilaginous 
tube is pulled out of the bony meatus. The posterior flap is 
now separated from the bone by means of the periosteum ele- 
vator, and the typical mastoid operation is performed, the 
antrum being entered in the manner already described in deal- 
ing with the technique of the mastoid operation. The extent 
to which the mastoid cortex shall be removed and the pneu- 
matic spaces broken down, must vary with each individual case. 
We not infrequently find, in cases of long-continued suppu- 
ration, which have resisted all methods of treatment other 
than operative, that the mastoid process has become sclerosed, 
its cellular structure practically obliterated, and that the only 
pneumatic space which exists is the antrum which, as we know, 
communicates directly with the middle ear. When this condi- 
tion is present, it is of course unwise to perform a typical mas- 
toid operation and remove the mastoid tip. This rule applies 
even when the entire mastoid is pneumatic. We not infre- 
quently meet with cases of chronic suppuration of the middle 
ear demanding this operation, in which the mastoid antrum 
is involved in the suppurative process. On opening the mas- 
toid cortex, in the usual manner, we find that the mastoid 
process is pneumatic throughout. It is not necessary in these 
cases to obliterate the entire pneumatic structure of the mas- 



EXPOSURE OF TYMPANIC VAULT. 549 

toid. The operator should proceed carefully and should break 
down all cells which seem to be diseased. No doubtful tissue 
should be left. When, however, perfectly normal pneumatic 
spaces are reached, these need not necessarily be obliterated. 
The operator must simply look upon this structure as being 
normal, and may then proceed with the subsequent steps of 
the operation. Experience has shown that infection in these 
spaces can be avoided at the time of the operation, and if they 
are not already diseased they need not be obliterated. As 
soon as the antrum has been entered, ocular inspection and 
the careful use of the probe will indicate to the surgeon 
how much of the mastoid process he must remove. In ad- 
vanced cases of cholesteatoma we frequently find the entire 
mastoid converted into a large cavity, filled by a cholestea- 
tomatous mass. In these cases, of course, the cortex must be 
ablated over the entire affected area so as to remove every 
vestige of the cholesteatoma. In other cases, we find evi- 
dences of purulent infection invading the cells even as far as 
the tip. In those cases the entire tip must be removed. The 
extent to which the mastoid is broken down must vary with 
each individual case, and must be governed by general surgical 
principles. After the mastoid has been thoroughly cleared out, 
to whatever extent is necessary, the next step is to break 
down the bony partition between the external auditory meatus 
and the artificial opening made in the mastoid. The removal of 
this bony partition should begin at a level with the upper wall 
of the meatus, the chisel being directed inward and slightly 
upward so as to follow the line of the upper wall of the canal. 

Instead of breaking down this partition, the operator may 
follow the plan advised by Stacke,* by first removing the 
external wall of the tympanic vault through the meatus. The 
external wall of the tympanic vault, as it will be remembered, 
is constituted by the upper and inner extremity of the bony 
canal. The removal of this bony plate exposes the epitympanic 
space, showing the malleus and incus in position. While it is 
exceedingly simple in the cadaver to remove the inner ex- 
tremitv of the inner wall of the bony canal through the meatus, 
and to expose the entire tympanic vault and the aditus ad an- 
trum in this way, it is somewhat difficult to carry out this step 
of the operation when the parts are more or less obscured by 

* Die operative Freilegung der Mittelohrraume, Tubingen, 1S97. 



D^ 



RADICAL OPERATION FOR CHRONIC OTORRHCEA. 



blood. The oozing from the cut surfaces quite frequently ren- 
ders this step of the operation difficult and tedious. I prefer, 
therefore, to enter the mastoid antrum in the typical manner 
already described, and to then break down the partition be- 
tween the artificial mastoid opening and the external auditory 
meatus. This is best done by dividing the partition first along 
the horizontal plane parallel with the upper wall of the external 

auditory canal. If the bony 
tissues could be divided 
along this line the aditus ad 
antrum would be reached. If 
the chisel is carried below 
this line, there is danger of 
injuring either the facial 
nerve or the horizontal semi- 
circular canal. In practice, 
in order to effect division of 
the bony tissues along the 
plane of the upper wall of 
the external auditory canal, 
a certain amount of bone 
must be removed below; 
consequently, the operator 
should enlarge the opening 
through the mastoid cortex 
until it assumes a funnel- 
shaped form, the apex of the funnel lying at the mastoid an- 
trum and the broad base of the funnel, including an area of 
the mastoid cortex and of the external auditory canal, the 
vertical diameter of which is equal to the vertical diameter of 
the external auditory meatus. In breaking clown the wall 
between the canal and this funnel-shaped opening in the mas- 
toid, the operator should remove a wedge-shaped piece of 
bone, the base of the wedge corresponding to the 'vertical 
diameter of the meatus and the apex corresponding to the 
aditus ad antrum — that channel which joins the mastoid an- 
trum with the tympanic vault. This removal may be effected 
either by means of the chisel or the narrow rongeur forceps. 
The goose-neck forceps, devised by Jansen for this purpose, 
are very convenient in certain cases. 

The important structures to be avoided lie just below the 
apex of this wedge-shaped piece of bone to be removed. They 




Fig. 145. — The tympanic vault and its con- 
tents exposed by the removal of its outer 
wall, and the division of the fibrous 
meatus transversely close to the mem- 
brana tympani. (Author's specimen.) 



PRECAUTIONS DURING OPERATION. 55 1 

are: the horizontal semicircular canal, which forms really 
the floor of the aditus ad antrum, and immediately below this, 
the aquaeductus Fallopii, which contains the trunk of the facial 
nerve. Lower still we have the oval window containing the 
stapes. If the operator proceeds from without inward, he may 
follow the upper wall of the external auditory canal inward 
until the aditus ad antrum is reached. He may follow the in- 
ferior wall of the canal inward for at least two thirds of its 
length. The removal of the bony partition along these lines 
will then reveal the prominence of the horizontal semicircular 
canal, and immediately below this, and often amalgamated with 
it, that of the aquaeductus Fallopii. If the posterior wall of the 
meatus is removed throughout its entire extent as far as the 
internal wall of the middle ear, either the horizontal semicir- 
cular canal or the aquaeductus Fallopii must be injured. The 
point w T hich the operator should remember is to follow inward 




Fig. 146. — Specimen showing appearance of bony cavity after the complete radical 
operation. (Author's specimen.) 

along the level of the inferior wall of the meatus for about two 
thirds of the length of this channel, while the bony tissue can 
be removed along the upper wall until the aditus ad antrum is 
reached. When this triangular or really quadrilateral piece of 
bone has been removed, the surgeon will be able to see dis- 
tinctly the prominence of the horizontal semicircular canal and 
the facial canal, and close inspection will reveal below this the 



552 



RADICAL OPERATION FOR CHRONIC OTORRHGEA. 



oval window. After these steps of the operation have been 
accomplished, the operator will then break away the floor of 
the tympanic vault — that is, the inner extremity of the superior 
wall of the external auditory meatus. This procedure, when 
completed, will disclose the entire middle-ear cavity as con- 
tinuous with the external auditory canal; the head and neck of 
the malleus with the short and long process will be readily 
seen, and below this possibly the remnants of the tympanic 
membrane. The body of the incus, with its short process in 
the cella incudis and its long process extending downward to 
the incudo-stapedial articulation, will also be made out. Above 
the head of the stapes the operator will see the prominent 
ridge which constitutes the aquasductus Fallopii, and just above 
this, and often continuous with it, the prominence of the hori- 
zontal semicircular canal. It is then simple, after this thorough 
exposure of the parts, to divide the incudo-stapedial articu- 
lation, if this is still intact, and to remove the malleus, incus, and 
any remnants of the drum membrane. All of this can readily 
be done without disturbing the stapes. After the ossicles have 

been removed, the entire cavity ex- 
posed should be curetted until firm 
bone is encountered in every direc- 
tion. 

The curette should also be intro- 
duced well into the tympanic orifice 
of the Eustachian tube, so as to cause 
a closure of this tube, if possible, to 
prevent subsequent infection of the 
middle ear from the naso-pharynx. 

All of the deeper bony dissection 
is best done with the aid of either the 
forehead mirror, using reflected light, 
or of the electric head lamp. 

After all carious bone has been re- 
moved and the haemorrhage stopped 
from all bleeding points, the operator 
next proceeds to line the cavity with 
epithelial flaps derived from the pos- 
terior wall of the fibro-cartilaginous meatus and from the con- 
cha. Several methods are much in vogue in forming these 
flaps. Stacke, in his earlier operation, advocated the splitting 
of the fibro-cartilaginous meatus along the posterior aspect, 




Fig. 147. — Complete Stacke- 
Schwartze operation. The 
mastoid cells and middle ear 
have been thrown into one 
large cavity, continuous with 
the external auditory meatus. 
(From dissections by the 
author.) 



MODIFICATIONS OF OPERATION. 



553 




Fig. 148. — Stacke-Schwartze opera- 



and tucking the two triangular flaps thus formed, the one up- 
ward and backward and the other downward and backward into 

the bony cavity formed by the en- 
largement of the fundus of the 
canal. 

Panse modified this procedure, 
converting the horizontal incision 
along the posterior wall of the 
canal into a T-shaped incision, by 
making one cut upward and an- 
other downward where the hori- 
zontal incision along the posterior 
wall of the meatus extends into 
tion. Formation of flaps by t ht concha. In this manner, two 

Panse s method. (From dissec- , . 

tions by the author.) quadrilateral flaps are formed, one 

which is turned upward and the 
other downward, so as to more perfectly line the cavity formed 
by the extensive removal of the bone. These two flaps are 
held in position by means of sutures which pass through the 
flaps and bend the upper flap for- 
ward and upward upon itself, while 
the lower flap is bent backward and 
downward upon itself. All sutures 
pass through the quadrilateral flaps 
and through the soft structures in 
the anterior flap. 

Another modification of the 
plastic operation is that of Koerner, 
who, instead of dividing the fibro- 
cartilaginous meatus by a horizon- 
tal incision, makes one horizontal 
incision along the upper and pos- FlG 
terior margin of the fibro-cartilag- 
inous tube and the other along the 
postero-inferior margin. This in- 
cision is extended out into the con- 
cha. In this way, a single quadri- 
lateral flap is formed, which can be forced backward into the 
bony cavity. 

The cartilaginous structure of the concha interferes mate- 
rially with the reflection of this flap backward into the bony 
cavity, which it is supposed to line. In order to obviate this 
37 




-Stacke-Schwartze opera- 
tion. The long tongue-shaped 
flap, formed according to Koer- 
ner's method, is seen drawn out- 
ward and backward by means of 
a clamp. (From dissections by 
the author.) 



554 



RADICAL OPERATION FOR CHRONIC OTORRHCEA. 



difficulty, Jansen,* of Berlin, advocates the dissecting out of 
the cartilage, thus making the flap thin and allowing of its easy 
displacement into the bony cavity. I have attempted this 
method in one case, and the result was fairly successful. 

Still another method is that recommended by Ballance,f 
in which a tongue-shaped flap is formed, which includes prac- 





FlG. 150. — Incision of concha to form Fig. 151. — Conchal flap sutured in posi- 
conchal flap. (Ballance.) tion. (Ballance.) 

tically the entire area of the concha. This flap is cut from 
the auricle by passing a thin knife into the external auditory 
meatus, just behind the tragus. The knife is then passed 
downward and made to divide the integument along the en- 
tire anterior, inferior, and posterior aspects of the concha, the 
incision stopped just below the anterior crus of the antihelix. 
The tongue-shaped flap thus formed is dissected up from the 
underlying cartilage and the cartilage is excised. This tongue- 
shaped flap is then turned upward and backward, and is held 
in position by retention sutures against the corresponding raw 
surface of the anterior auricular flap — that is, the two raw auric- 
ular surfaces are brought together. It will be seen that in this 
way a cutaneous flap is formed which, on turning the auricle 
backward, fits for a considerable distance into the upper and 
posterior portion of the bony cavity, and thus serves to line 
this with integument. 

Ballance also advocates the subsequent lining of the en- 
tire bony cavity, at a period of ten days after the primary opera- 

* Verhandlungen der deutschen otologischen Gesellschaft, Siebente Versamm- 
lung in Wurzburg, p. 196. f Loc. cit. 



MODIFICATION OF PANSE'S METHOD. 



555 



tion, with skin grafts after the Tiersch method, the posterior 
wound being reopened for the purpose of inserting the grafts. 
From my own experience, I can say I have formed flaps in 
all of the above-mentioned ways, and believe that the exact 
flap to be formed must depend upon the particular conforma- 
tion of the parts in each individual case. I might say, in re- 
gard to the Panse method, that for some time I have adopted 
a modification which has been very valuable to me. Instead 
of bending the upper and lower flaps backward upon them- 
selves and suturing them to the anterior flap, to which they are 
already attached, I have passed deep sutures of heavy catgut 
through the entire depth of these flaps and sutured them to 
the periosteal margin behind the mastoid wound. The upper 
suture passes through the outer extremity of the upper quadri- 
lateral flap and through the periosteal margin of the posterior 
wound adjacent. When traction is made upon this suture the 
quadrilateral flap is pulled upward, outward, and backward, so 
that its cutaneous surface forms a lining for the upper part of 
the bony cavity by its raw surface being forced against the 
walls of this cavity. The lower quadrilateral flap is attached to 
the periosteal margin of the wound behind and below in ex- 
actly a similar manner. It will be seen that the effect of these 





FlG. 152. — Method of lining the operation wound by means of a skin flap taken from 
the neck, just below the tip of the mastoid. (Passow's method.) A. e, f, g, 
Flap cut from below. B. Flap rotated into postero-auricular opening and su- 
tured in position. In this plastic operation a permanent retro-auricular opening 
remains. 



two sutures is not only to partially line the bony cavity with the 
flaps thus formed, but also to enlarge considerably the orifice 
of the external auditory canal so that practically the entire 
field of operation can be inspected by reflected light through 
the meatus. When these deep sutures are tied, it will be found 
that the superficial tissues, which have been divided, will fall 



556 



RADICAL OPERATION FOR CHRONIC OTORRHCEA. 




backward into fairly good approximation. These sutures be- 
ing of catgut, have been buried,, and have served to hold not 
only the flaps in place and to force them 
respectively well upward and downward 
into the canal, but have also served to 
bring the cutaneous margins of the ex- 
ternal wound in pretty close apposition. 

It will be understood that whatever 
form of flap operation is chosen, and in 
whatever manner these flaps are secured 
in place, the posterior wound is ultimate- 
ly to be closed completely by either silk, 
silkworm-gut or catgut sutures. My 
own preference is to put in several su- 
tures of silkworm-gut, passing through 
the entire thickness of both the anterior 
and posterior flaps. These sutures pierce 
the integument of the anterior and pos- 
terior flaps anywhere from five sixteenths 
of an inch 
to half an 
inch from 
their mar- 
gins respectively, and also, be- 
ing passed deeply, support the 
tissues and insure firm union of 
the deeper structures through- 
out. At intervals between these 
silkworm-gut sutures, I have 
been in the habit of inserting a 
few superficial sutures of rather 
fine silk, so as to secure perfect 
approximation of the entire line 
of incision. In certain cases. I 
have used nothing but catgut su- 
tures, the advantage in their use 
being that they are absorbed, 
and the inconvenience to the pa- 
tient, of their removal, is avoid- 
ed. Provided the suture material is sterile, it is of very little 
importance what kind of suture material is employed to hold 
the flaps in position. 



Fig. 153. — The formation 
of flaps for lining the 
bony cavity after radi- 
cal operation, a, Flap 
taken from posterior 
surface of auricle ; b, 
c, Flaps taken from 
tissues of neck below 
mastoid. A post-auric- 
ular opening remains 
after this operation. 
(Method of Jansen and 
Forselles.) 




Fig. 154. — Method of lining bony 
cavity with skin flaps, a, Flap 
taken above from posterior mar- 
gin of mastoid wound ; b, Flap 
taken from posterior margin of 
mastoid wound below ; these two 
flaps are dissected upward and 
then turned into the tympanic 
cavity ; c, Area along which skin 
is undermined after these flaps 
have been formed so as to enable 
approximation of the edges of the 
wound over the flaps. (Method 
of Schwartze and Kretschmann.) 



LINING OF CAVITY IN MASTOID. 557 

In all of the methods of operation previously detailed, the 
idea of the operator should be to drain the middle ear entirely 
through the meatus, closing the wound behind the ear com- 
pletely. Certain operators, as Passow, Jansen, Reinhardt, 
Kretschmann, and Schwartze, have advocated lining the cavity 
already formed in the mastoid, with cutaneous flaps obtained 
from the integument of either the anterior or posterior flaps, 
thus leaving a permanent opening behind the ear. While it is 
possible by any of these methods to form a tegumentary lining 
for the cavity, composed of mastoid cells, middle ear, and ex- 
ternal auditory meatus, the unsightly deformity which results 
from a large permanent opening behind the ear seems to me 
to constitute a radical objection to all of these methods. 

The methods of formation of these flaps will be easily under- 
stood from the appended figures, which are reproduced from 
the excellent work of Jacobson.* 

In a number of my cases, for the last year, I have dissected 
out more or less of the cartilage of the concha, and in every 
instance have found the results of the plastic operation were 
much better when this was done than when the flaps were 
allowed to remain of their original thickness. I have also made 
use of the tongue-shaped flap, with the dissecting out of the 
cartilage after the Ballance method, but have slightly modified 
the manner of holding the flap in position. 

After the tongue-shaped flap has been cut from the concha 
and the cartilage dissected out, the cutaneous flap is pulled up- 
ward and backward into the posterior wound and its raw surface 
applied to a corresponding raw surface on the anterior flap con- 
sisting of the auricle. In other words, the flap is bent back- 
ward upon itself and the tissues are sutured together, raw sur- 
face to raw surface, by means of catgut sutures. In this way, 
the meatus is not only enlarged, but by the stitching up of the 
tongue-shaped flap, in the manner above described, a cutaneous 
lining is formed for the upper portion of the bony cavity, when 
the auricle is replaced and the posterior wound sutured. 

I have never attempted to line the middle-ear cavity by 
means of the Tiersch grafts, by reopening the posterior wound, 
as advocated by Ballance, but in one instance secured an admi- 
rable result by lining the entire wound through the external 
auditory meatus, the opening which was left after the plastic 

* Lehrbuch der Ohrenheilkunde fur Aerzte und Studirende, L. Jacobson and L. 
Blau, Leipzig, 1902. 



558 RADICAL OPERATION FOR CHRONIC OTORRHCEA. 

operation being so ample that the grafts could be inserted with- 
out great difficulty. Instead of opening the posterior wound at 
a later period for the introduction of Tiersch grafts, I have lately 
had very good success in introducing these grafts at the time of 
the primary operation. After all carious bone has been re- 
moved and the flaps formed from the meatus and concha by 
any of the methods above detailed, as the necessities of the 
case have seemed to indicate,, I have then proceeded to line the 




Fig. 155. — Ballance's instruments for skin grafting. A, Large razor for cutting 
grafts ; B, Pipettes for removal of air and blood from beneath the grafts when 
in position ; C, Needle for manipulating graft ; D, Blunt instrument for pressing 
grafts on bony wall and for packing pledgets into tympanic cavity to hold grafts 
in position ; E, Broad spatula; upon which graft is spread and from which it is 
carried into the tympanic cavity. 



entire cavity of the middle ear as completely as possible by 
means of Tiersch grafts taken from the thigh of the patient. 
As large a graft as possible should be cut and carefully slid off 
from the razor on to a broad spatula. These grafts are more 
easily transferred if they are slightly moistened with a few 
drops of a normal salt solution. Care should be taken to spread 
the graft out flat upon the spatula and to see that its edges do 
not curl under. The graft is then quickly but carefully slid 
from the spatula into the bony cavity which it is intended to 
line. To transfer the graft in this way a long, straight needle 
seems to be the best instrument. The spatula having the graft 



TIERSCH GRAFTING. 559 

in position is carried as close to the operation wound as pos- 
sible. The edge of the graft nearest the wound is then carried 
rapidly from the spatula across the wound surface from behind 
forward. While this manipulation, from its description, may 
seem to be difficult, it is in reality very simple to slide the graft 
from the spatula into the wound, and to so place it that it will 
completely fill the fundus of the canal, the roof of the tym- 
panum, and the deeper portion of the spur of bone which forms 
the wall of the facial nerve and horizontal semicircular canal. 
It is important that the bony cavity should be as dry as possible 
before the graft is put in position; to this end, the cavity may 
be packed with sterile gauze until the operator is ready to in- 
troduce the graft. The packing is then removed by an assist- 
ant and the graft quickly slid into position. In spite of all care 
there will be a little oozing under the graft. This blood is best 
removed by means of a thin, fine glass pipette introduced under 
the margin of the graft, suction being applied to the pipette by 
the lips of the surgeon or of an assistant. In this way all air 
bubbles are removed and the graft falls naturally into position 
upon the surface. This ingenious method of applying the grafts 
was, I think, first suggested by Mr. Ballance. After the graft 
is in place, it should be maintained in position by a firm packing 
of pledgets of sterile cotton. These pledgets are frequently 
impregnated either with aristol, xeroform, iodol, or some such 
antiseptic powder, the idea being to keep the bony cavity as 
dry as possible in order to favor the vivification of the grafts. 
These cotton pledgets are packed upon the surface of the 
graft, and are pressed firmly inward upon the bony wall by 
means of a smooth steel instrument which allows the cotton 
pledget to be manipulated considerably, while, at the same time, 
the smooth surface of the instrument does not catch it and tend 
to pull the graft away from the bony surface to which it is 
applied. The entire cavity is filled with these cotton pledgets, 
the average number of pledgets introduced being somewhere 
between ten and fifteen. After the graft has thus been care- 
fully applied, the posterior wound is sutured in the manner 
already detailed. Unless there is a rise in temperature, the 
dressing need not be changed for eight or nine days. At the 
end of this time the posterior wound is usually found united. 
Careful removal of the cotton pledgets by means of the forceps 
will generally show that the graft has taken, at least, over a part 
of the surface to which it was applied, and frequentlv over the 



560 RADICAL OPERATION FOR CHRONIC OTORRHCEA. 

entire surface. In this way dermatization of the tympanic cav- 
ity is effected in a much shorter time than by the other method. 

It is well here to speak of the fact that if the dressing in 
these cases is not changed before the eighth or ninth day, 
that when the dressing is taken down, the odor of the wound 
will be exceedingly foul; this has been present in all of my cases,, 
and yet, in very few have the grafts failed to take. The odor 
is apparently due to the casting off of the superficial epithe- 
lium of the graft. This epithelium becomes necrotic and these 
circumstances account for the foul odor of the dressing. In 
no case have I failed to get partial union, even though the 
middle ear was grafted under most unfavorable circumstances, 
and in most of the cases, primary union has resulted through- 
out. The presence of the odor should not, therefore, lead the 
surgeon to believe that the result of the grafting operation 
is unsuccessful. Following the advice of Ballance, I have 
been in the habit of syringing these cases at the time of the 
first dressing with a solution composed of equal parts of ordi- 
nary peroxide of hydrogen and sterilized water. This renders 
the wound perfectly sweet. After the peroxide irrigation 
the parts are irrigated with a warm sterile normal salt solution; 
after the first dressing the dressing is changed daily. It may 
not be possible to remove all of the cotton plugs at the time 
of the first dressing, nor is it advisable to employ undue force 
or prolonged manipulation to remove all of the pledgets at 
this time. A few of the outer pledgets may be removed, and 
the irrigation performed in the manner above described. It is 
then my practice to dust a little aristol or xeroform into the 
canal, after drying the parts thoroughly with sterilized cotton, 
to pack the canal loosely with a strip of sterilized gauze, and 
to reapply an antiseptic dressing covering the entire ear and the 
mastoid wound. This dressing should be changed daily, the. 
irrigation of the peroxide repeated at each dressing, and a 
search made for the remaining pledgets. At each daily dress- 
ing any pledgets remaining should be removed until the entire 
number have been extracted from the canal. At the end of 
ten days or two weeks, in favorable cases, all dressings behind 
the ear may be removed. It is then well to protect the line of 
incision by a collodion dressing, the ear being left out. The 
canal may then be left open or be packed loosely with sterile 
gauze, as the operator may deem wise. 

Regarding the results following these operations: Out of 



ACCIDENTS DURING OPERATION. 561 

seventy cases operated upon, fifty-three were cured, eight were 
improved, one was unimproved, in one the result is unknown, 
and seven are still under treatment. 

I do not believe that subsequent experience will demon- 
strate the necessity of doing a secondary operation, in the ma- 
jority of cases, in order to secure dermatization of the tym- 
panic cavity by means of the Tiersch graft. Of course, second- 
ary operations for this purpose will be necessary in some cases, 
particularly in those where the purulent discharge has been 
very profuse, and where it is practically impossible to obtain 
a fairly aseptic wound at the time of the first operation. Cer- 
tain cases of this kind have come under my observation. Here, 
I simply pass the deep sutures already mentioned, but do not 
suture the cutaneous wound. As soon as the middle-ear cavity 
seems to be in a fairly aseptic condition, the grafts are then ap- 
plied and the superficial wound sutured. The passage of the 
deep sutures insures the maintenance of an ample meatus and 
rather favors the subsequent coaptation of the cutaneous parts, 
while it in no way interferes with the application of the grafts. 

Accidents during Operation. — Regarding the dangers of this 
operation, a few remarks may not be out of place. The danger 
which we usually seek to avoid is injury of the facial nerve. 
This can be avoided in almost every instance by carefully fol- 
lowing the upper wall of the canal, removing the external wall 
of the epitympanic space — that is, the roof of the meatus close 
to the middle ear — and in this way exposing the aditus ad an- 
trum and anterior portion of the antrum. The prominence of 
the semicircular canal of the aquseductus Fallopii will then come 
into view. If these parts are exposed and recognized, the cu- 
rette may then be used quite freely but cautiously, both upward 
and downward, in order to enlarge the opening between the 
antrum and the middle ear without injuring the facial nerve. 
Of course, throughout the entire procedure the face should be 
carefully watched for any evidences of mechanical irritation 
of the facial nerve by instruments. In addition to the danger of 
facial paralysis, the operation can not be absolutely free from 
danger to life. The middle cranial fossa occasionally lies so low- 
that even with the most careful use of the chisel, the removal of 
the roof of the meatus will expose the dura. This has happened 
to me in four cases. In two of these instances the dura itself 
was wounded by a spicule of bone, and on carefully introducing 
the probe for purposes of exploration the probe went directly 



562 RADICAL OPERATION FOR CHRONIC OTORRHCEA. 

into the cerebral substance. Both of these cases made a com- 
plete recovery. 

Another accident which has happened in my own case, and 
to at least two of my colleagues, has been the accidental ex- 
posure of the lateral sinus, where this vessel lay very far for- 
ward. It would even be possible to wound the lateral sinus, 
during the operation, where this vessel was greatly misplaced, 
in spite of the greatest care on the part of the operator. While 
accidents of this kind must be exceedingly rare, their occa- 
sional occurrence can not be entirely avoided, even by exer- 
cising the greatest care in technique. The surgeon should 
always remember, therefore, in performing this operation, that 
he is liable to expose the dura, or even to open it, even in the 
middle cranial fossa or over the lateral sinus, at some stage of 
the operation. It is therefore of the utmost importance that 
the operation be conducted with the greatest attention to asep- 
tic technique. In those cases where these accidents have hap- 
pened in my own practice, I have attributed the recovery of 
my patients solely and entirely to the fact that the technique of 
the operation was as perfect as I could make it. The mere 
exposure of the dura in the middle fossa, or the exposure of 
the lateral sinus should not ordinarily be followed by any symp- 
toms. As soon as the surgeon discovers that the cavity of the 
cranium has been invaded, he should pack off this area, using 
a strip of iodoform gauze for the purpose, so as to completely 
isolate the part exposed from the operative field; he may then 
proceed to rapidly remove all deeper foci of purulent infection 
by the free use of the curette and gouge, so as to prevent sub- 
sequent infection of the deeper parts from the original focus 
of suppuration. Where the field of operation is so contracted 
as to render it impossible to pack off the dural area separately, 
care must be taken in clearing out the deeper portion of the 
wound to sweep all of the detritus downward and outward, 
rather than upward and outward, in which latter instance it 
would pass directly over the exposed dura and be liable to 
infect it. In those cases where the brain substance is not 
wounded or the sinus opened, the mere exposure of the dura 
need not deter the surgeon from proceeding in the ordinary 
manner — that is, the cutaneous flaps may be formed in the 
usual way, sutured in position, and the entire posterior wound 
closed by sutures. In packing the canal, it has been my custom, 
excepting in those cases where the canal was so narrow as to 



ACCIDENTS DURING OPERATION. 563 

render it impossible to pack off the exposed sinus or exposed 
dura in the middle fossa separately from the other wound, by 
introducing a separate packing over the dural area, so as to 
avoid any infection of the meninges or of the sinus from the 
discharge from the canal. It is also wise in these cases to change 
the dressing every second clay, thus keeping the parts clean. 
Where the brain substance is entered, if the area has been kept 
thoroughly cleansed prior to the time of operation, and if the 
operator is convinced after curettement that no focus of infec- 
tion has been left, he may then close the wound completely, as 
above described. If there is any doubt about the cleanliness 
of the wound, however, the surgeon will do well to pack off the 
site of the dural wound separately, and to defer suturing the 
posterior wound until at least ten days after the primary opera- 
tion, packing the parts firmly with iodoform gauze, so as to 
guard against secondary infection. 

Among one of the rarer accidents which may follow the 
radical procedure is an extensive perichondritis of the auricle. 
This occurred in one of my cases, from no assignable cause. 
In this instance the perichondritis was very extensive, and in 
spite of prompt operative interference considerable deformity 
of the external ear resulted. A similar case is reported by 
Politzer.* 

* Lehrbuch der Ohrenheilkunde, 4th ed., Stuttgart, p. 462. 



SECTION IV. 

THE SURGICAL TREATMENT OF INTRACRANIAL 
COMPLICATIONS OF AURAL SUPPURATION. 



Fig. 156. — Lateral aspect of skull, showing Reed's base line. This is a horizontal 
line drawn from the lower margin of the orbit to the occipital protuberance. 
This line will pass through the centre of the external auditory meatus. In the 
figure, the line is divided into quarter inches. C, A point one inch above the 
centre of the meatus, the site of election for entering the cranial cavity for ex- 
ploratory purposes. D, A point an inch and a quarter behind, and an inch and 
a quarter above a horizontal plane, passing through the centre of the external 
auditory meatus ; this is the point usually given as the site of election for open- 
ing a temporo-sphenoidal abscess. If the opening into the cranial cavity is 
made at the point C, as advised in the text, it will be seen that it is only neces- 
sary to enlarge the opening in the bone backward in order to reach the portion 
of the temporo-sphenoidal lobe indicated by D. E is a point on Reed's base 
line, seven eighths of an inch behind the external auditory meatus. This point 
corresponds to the knee of the lateral sinus ; the knee of the sinus may be found 
in front of this point or sometimes behind it. The site of election for opening 
a cerebellar abscess is a point one and one half inches behind the centre of the 
meatus, measured along Reed's base line, and a quarter of an inch below this 
line. F in the figure represents a point two and a half inches behind the 
centre of the meatus on Reed's base line. The opening may be extended pos- 
teriorly toward the median line, as far as the point F. in exploring for a cerebel- 
lar abscess. A, Fissure of Rolando. This fissure is found by drawing a line 
from the root of the nose over the top of the head to the occipital protuberance. 
A point .557 of the distance backward on this line is then taken ; this point cor- 
responds to the upper end of the Rolandic fissure. As the fissure extends down- 
ward and forward at an angle of 67"" with this line, it is only necessary to take a 
piece of paper so folded as to make an angle of 67°, and applying one side of 
the triangle to the line already drawn, the other side of the triangle will cor- 
respond to the fissure of Rolando. This fissure is about three and a half inches 
in length. B, Fissure of Sylvius. To find this fissure, draw a line parallel to 
Reed's base line from the external angular process of the frontal bone. Take a 
point one and one quarter inches behind the external angular process on this 
line and a quarter of an inch above it. This marks the anterior extremity of 
the fissure. Next find the parietal eminence and from this point draw a line 
downward, perpendicularly to Reed's base line. On this line mark a point 
three quarters of an inch below the parietal eminence ; this gives the second 
point. A line drawn from the anterior extremity of the fissure, through this 
second point and extending backward for four inches, will mark the fissure of 
Sylvius. (Author's specimen.) 

(566) 



THE SURGICAL TREATMENT OF THE 

INTRACRANIAL COMPLICATIONS 

OF AURAL SUPPURATION. 



When it has been decided that the intracranial structures 
are involved either subsequent to an operation on the mas- 
toid or when the case first comes under observation, it is wise 
to institute surgical measures for the relief of the condition. 
It has been argued that, from the great mortality following 
such measures, they are not justifiable; but when we remem- 
ber that the only chance of relief lies in surgical interference, 
it seems wrong to refuse the patient this opportunity. 

In purulent meningitis surgical interference offers less 
promise than in epidural or cerebral abscess, or in sinus throm- 
bosis, when prompt action on the part of the surgeon often 
saves life. It is only when unmistakable symptoms of extensive 
meningitis occur that we should hesitate in performing an oper- 
ation in any of these cases. 

It is well, in undertaking an operation for the relief of an 
intracranial lesion following a middle-ear inflammation, to re- 
member the advantage of having the opening in the soft parts 
sufficiently ample to permit of extending the opening in the 
skull in various directions, if desirable, without enlarging the 
cutaneous incision. 

The operator may wish to explore the middle fossa, the 
sinus, and the cerebellum at the same operation, and to expose 
each of these areas, as a separate procedure would entail the 
expenditure of much valuable time. It is wise, therefore, to 
expose the bony surface over an area which includes the vari- 
ous sites of election for entering the cavity (Fig. 156). The 
author has found that the exposure is best effected by the 
displacement of a semicircular flap, as shown in Plate XIV. 
This flap is formed by extending the incision, made at the 
time of the mastoid operation, forward above the zygoma for 
38 (569) 



5;o TREATMENT OF INTRACRANIAL COMPLICATIONS. 

a distance of an inch and a half. From the middle of the 
original mastoid incision an incision is made backward to the 
occipital protuberance. This incision is slightly curved, the 
convexity being directed upward. If the soft parts are now 
dissected up, a large flap can be turned down upon the neck, 
exposing the surface of the cranium. The flap is supplied by 
the vessels which enter from below, and the danger of slough- 
ing is avoided. All attached muscles are divided longitudi- 
nally, and hence their action is in no way destroyed. 

In dissecting up this flap, the periosteum is not detached; 
this is undisturbed, except where the bony wall is removed to 
effect an entrance to the cranial cavity. 



PLATE XIV. 








-^JEHf"*" 



fZ^ i 



" 



Exploration of Middle Cranial Fossa, Lateral Sinus, and Cerebellum. 
Ligation of Internal Jugular. (Author's dissection.) 



CHAPTER XXX. 



SINUS THROMBOSIS. 



Where the mastoid has been previously opened, the sim- 
plest means of exposing the lateral sinus is to remove the bone 
directly behind the mastoid antrum and perforate the skull at 
a point about seven eighths of an inch behind the centre of the 
bony meatus, and a quarter of an inch above a horizontal plane 
passed through this point. In other words, the sinus will be 
exposed by perforating the skull at a point approximately half 
an inch behind the posterior margin of the external auditory 
meatus. The position of the sinus varies considerably in dif- 
ferent individuals, but it is seldom placed farther backward than 
this, although occasionally it may lie three quarters of an inch 
behind the posterior margin of the osseous meatus. 

Whenever the sinus is to be explored, too much attention 
can not be paid to the technique of the operation. The sur- 
geon should always remember that he is possibly exposing a 
healthy blood vessel of considerable size, and that, therefore, 
the dangers of infection are many, unless perfect asepsis is 
observed. If the mastoid operation has been done at the same 
time, it is well to have all instruments resterilized, and the field 
of operation surrounded either by dry sterilized towels or by 
fresh towels moistened in a solution of bichloride of mercury 
of a strength 1-1,000; the hands of the operator and those of 
his assistant should also be recleansed before proceeding with 
this exploratory operation. 

In exposing the sinus the bone may be removed rapidly, 
as there is very little danger of perforating the sinus wall by 
means of the chisel or gouge, if ordinary care is used. As soon 
as the chisel has perforated the inner table and the dura is 
exposed, the opening should be rapidly enlarged upward and 
downward by means of the rongeur forceps. Care must, of 
course, be taken not to endanger the wall of the sinus by the 

(S7X) 



572 SINUS THROMBOSIS. 

use of this instrument. This warning is particularly necessary 
in dealing with those cases where the sinus wall is necrotic, as 
here even a slight amount of violence may break down the wall 
of the blood vessel. It is sometimes wise, previous to intro- 
ducing the rongeur forceps, to pass a director cautiously be- 
tween the dura and the skull, so as to separate the dura from the 
bone and allow the passage of the lower blade of the rongeur 
into the cranial cavity, thus enabling the surgeon to enlarge the 
opening with perfect safety. 

In exposing the sinus for purposes of exploration, it should 
be remembered that it is necessary to remove the bony covering 
for a considerable distance. It is never wise to assume that 
the sinus has been properly explored unless it has been uncov- 
ered for a distance of at least three quarters of an inch, and it 
is better to expose it over a longer rather than over a shorter 
length. The area of exploration should begin at that part of 
the sinus lying just behind the mastoid antrum. The bone over 
the sigmoid groove should then be removed, so as to expose 
the knee of the sinus, and as far down toward the bulb as pos- 
sible. It is no easy matter to determine either by inspection or 
palpation whether or not the vessel is perfectly healthy. Some 
information may be gained by taking into consideration the 
color of the dura, the presence or absence of pulsation in the 
sinus, both upon inspection and palpation, and the aspiration 
of the sinus on deep inspiration. On palpation, if the sinus is 
normal, the wall of the vessel feels smooth and yielding to 
the touch, distinct pulsation is usually felt: by moderate pres- 
sure the finger is able to map out somewhat roughly the lateral 
extent of the venous channel. In other words, the normal 
sinus feels exactly as any large vein would feel under the finger, 
its fluid contents being easily expelled, and the channel filling 
rapidly with fluid blood as soon as the pressure is removed. 
Pressure at the lower part of the sinus will cause a slight dilata- 
tion of that portion of the channel above the palpating finger. 
In spite of all these signs, however, it is entirely possible that 
a small clot in the sinus may be occasionally overlooked. If 
the surgeon is in the least doubt, therefore, as to whether or 
not the sinus is normal, the only course is to make an explora- 
tory incision. 

In a former edition I advocated puncture of the sinus wall 
for exploratory purposes by means of the aspirating needle. 
Experience has taught me that exploratory puncture of the 



EXPLORATION OF SINUS. 573 

sinus is absolutely without value, as a parietal clot may be 
punctured, fluid blood may be withdrawn by the aspirating 
needle, and the operation prove entirely useless, therefore, for 
exploratory purposes. The only way of determining the pres- 
ence of a clot in the sinus is to make a good free incision in 
the sinus wall. This should be done preferably at the lower 
portion of the exploratory opening — that is, just below the 
knee of the sinus. The vessel should be compressed by the 
finger above, and a sharp bistoury made to divide the wall of 
the vein longitudinally for a distance of about a quarter of an 
inch. If free haemorrhage occurs from below, the ringer should 
be placed just below this opening. If the channel is normal, 
free haemorrhage will then occur from above. The exploratory 
operation may then be considered as having revealed a per- 
fectly normal sinus. A strip of iodoform gauze, one extremity 
of which has been folded over upon itself several times so as 
to form a cylindrical compress, is then placed over the opening 
in the sinus, and the remainder of the strip of gauze is packed 
down upon this little compress and held in position by the 
finger of an assistant. In this manner the haemorrhage is easily 
controlled. If, upon making an incision in the lower portion 
of the sinus, free haemorrhage does not occur, the pressure 
above should be taken off, to see if haemorrhage occurs from 
above. The absence of haemorrhage in either direction natu- 
rally indicates the presence of a clot. In cases where there is 
no haemorrhage upon removing all pressure after incision of 
the sinus wall, the incision in the wall should be extended up- 
ward for at least a quarter of an inch more, thus making the 
incision in the wall one half an inch long. A blunt curette 
should then be introduced into the lumen of the sinus, first 
downward toward the bulb, and the clot carefully but thor- 
oughly removed. The curette should be passed well down- 
ward into the bulb, and haemorrhage from below secured, if 
possible. After haemorrhage from below has been established, 
it should be controlled by a pledget of gauze packed over the 
lower portion of the opening in the sinus, in the manner already 
described, and the curette should then be used in the opposite 
direction upward toward the torcular, and the clot broken down 
in this direction until free haemorrhage results. 

It is well to remember here, that while it is imperative to 
establish, if possible, free haemorrhage from below, free haemor- 
rhage from above is not so important. If free haemorrhage 



574 SINUS THROMBOSIS. 

from below does not occur, it indicates that the clot has extend- 
ed downward through the bulb and into the internal jugular 
vein, from which point it is continually infecting the general 
circulation by the venous tributaries which enter the internal 
jugular below the base of the skull. If. however, the sinus is 
completelv plugged at the bulb, systemic infection can scarcely 
take place from any point above the jugular bulb, consequently 
it is well not to curette out the upper portion of the wound too 
thoroughly or too persistently. If there is a soft clot in this 
region and it can be broken down easily by means of the 
curette, free haemorrhage being established, then the clot 
should be broken down. If. however, the clot seems very firm 
and extensive, it is quite possible that it may extend well out 
toward the torcular. and that its upper portion may be non- 
infectious. It would, therefore, be unwise to disturb such a 
clot, as further decomposition would probably be avoided by 
properly curetting and packing the sinus wound with iodoform 
gauze. While we know from autopsies that infection through 
the opposite veins, through the torcular Herophili, does occur, 
such cases are so uncommon as to warrant their being practi- 
cally disregarded — certainly at the time of primary operation. 
and the aim of the surgeon should be to prevent infection from 
the sinus through the jugular of the same side. 

In cases where there is evidence of profound systemic infec- 
tion, the surgeon should remember that the mere fact that free 
haemorrhage occurs from below after opening the sinus does 
not indicate necessarily that the jugular has not been involved. 
As the channel through which infection of remote parts of the 
body occurs is a continuation of the lateral sinus — that is. the 
internal jugular vein — it often becomes necessary to cut off 
this large afferent channel in order to prevent the further ab- 
sorption of septic material. If the case has been under obser- 
vation for some time, it is possible that the surgeon may make 
a diagnosis of extension of the thrombus into the internal ju- 
gular. Such a diagnosis would depend upon great temperature 
fluctuations — that is. a temperature rising suddenly to 105° or 
io6 c . and then falling spontaneously in a few hours to normal 
or subnormal. In addition to this symptom, there would be 
other evidences of poisoning, such as asthenia, emaciation, and 
profuse perspiration. Locally, it is sometimes possible, in cases 
where the clot has extended into the internal jugular vein, to 
make out. upon palpating the neck, a tense, cord-like band fol- 



PLATE XV. 



■:,_ 



\ 




Dissection of Internal Jugular Vein, showing Free Venous Anastomosis 
on this Side as contrasted with Plate XIV. 

(Opposite side of same subject, author's dissection.) 



DIAGNOSIS. 575 

lowing the course of the internal jugular. Many authors seem 
to lay considerable stress upon this point; personally, I have 
never observed this physical sign. We must remember that 
the upper portion of the internal jugular vein lies deeply, the 
vessel being covered by the digastric muscle, deep cervical 
fascia, the parotid gland, the platysma, and the integument. 
Bearing in mind the fact that the deep lymphatic channels of 
the neck, like the deep cervical fascia, follow the general course 
of the vessels, and remembering how quickly these glands be- 
come involved whenever any septic process occurs in the adja- 
cent region, it is at once evident that a thrombus in the internal 
jugular may hardly be recognized by palpating the neck until 
this thrombus had extended well down the lumen of the vein; 
certainly, below the level of the larynx. In a number of my 
own cases there has been a hard, brawny swelling in the region 
of the parotid gland and along the anterior border of the sterno- 
mastoid muscle. In some cases I have been able to detect a 
tender point just at the anterior border of the muscle and just 
behind and above the angle of the jaw. The cord-like feeling, 
however, which is said to be indicative of the presence of the 
thrombus in the internal jugular vein, I have never observed. 
General tumefaction, then, and a tenderness along the anterior 
border of the sterno-mastoid muscle, together with great fluc- 
tuations in temperature, would lead the surgeon to suspect in 
any given case of purulent otitis, with or without mastoid in- 
volvement, that the infecting process had possibly extended 
from the sinus into the vein. I believe, however, that an abso- 
lutely certain diagnosis can only be made at the time of opera- 
tion. If, when the lateral sinus is explored in the manner 
detailed in the preceding pages, free haemorrhage does not 
occur from below, or even if there is considerable haemor- 
rhage from the lower end of the vein, if the surgeon finds the 
tissues just behind the angle of the jaw brawny and evidently 
infected, and if the fluctuations in the temperature have been 
well marked, he should not be content with clearing out the 
thrombus from the lateral sinus alone, but should immediately 
proceed to cut off the return circulation through the internal 
jugular vein. Ballance was the first to recognize the impor- 
tance of this procedure. But in the earlier operations a liga- 
ture was simply applied to the vein below the point at which 
the thrombus was found. In some instances, the vein was 
opened and the blood channel washed out with an antiseptic 



576 



SINUS THROMBOSIS. 



solution injected upward until the solution flowed out through 
the opening in the lateral sinus above. For a number of years 
surgeons have pursued the plan of completely excising the in- 
fected vein. The operation is best performed as follows: After 
the sinus has been explored and curetted, in the manner already 
described, the shoulders of the patient are elevated upon a 
pillow, thus rendering the sterno-mastoid muscle tense. The 
neck is then cleansed from the clavicle to the mastoid, the 
tissues being manipulated very carefully in order to prevent 
the breaking down of any clot which may be present in the 
jugular and the detachment of an embolus from any thrombus 
which may lie in the vein. An incision is then made from the 
sternal attachment of the sterno-mastoid muscle upward to the 
tip of the mastoid, the incision following the anterior border 
of the sterno-cleido-mastoid muscle. The integument is first 
divided, and the surgeon then observes the oblique fibres of 
the platysma. The platysma varies in thickness considerably 
in different individuals. At the lower part of the neck the 
muscle is very thin, while above it may be quite thick. As 
soon as the integument and the platysma are divided, the ante- 
rior border of the sterno-mastoid muscle comes into view. By 
means of retractors, the margins of the wound are separated, 
the sterno-mastoid being pulled backward. The deep fascia 
of the neck is then seen, and upon opening this the sheath of the 
vessels is found to lie immediately beneath the anterior border 
of the muscle. The common sheath of the vessels, it will be 
remembered, contains the common carotid artery, the internal 
jugular vein, and the pneumogastric nerve. The vein always 
lies to the outer side of the artery, low down in the neck, lying 
somewhat in front and to the outer side, while higher up in 
the neck it crosses the carotid just about at the point of bifur- 
cation of this vessel into the external and internal carotid arter- 
ies. It then follows the course of the internal carotid artery, 
and at the base of the skull lies on the outer side and slightly 
behind this vessel. The pneumogastric nerve lies between the 
vein and the internal carotid above and between the vein and 
the common carotid below. It also lies a little behind these 
vessels. After the sheath of the vessels has been opened, the 
vein is easily recognized by its dark-bluish color. Firm pres- 
sure at the root of the neck will cause the vein to fill with blood, 
and it can thus be more easily recognized. The first step of 
the operation is to clear the vein as thoroughly as possible 



OPERATION. 577 

from the sheath. This is best clone by some blunt instru- 
ment, such as the handle of the scalpel or the closed blades of a 
pair of blunt-pointed scissors, the connective tissue overlying 
the vein being raised cautiously by a pair of forceps and torn 
along the axis of the vessel by means of the blunt scissors or 
by means of a director; care is necessary in order to thoroughly 
separate the vessel from the pneumogastric nerve. Although 
the nerve lies behind the vessel, it is sometimes adherent to the 
sheath of the internal jugular. Unless care is taken to recog- 
nize the nerve at the time of the dissection, it may be included 
in a ligature passed around the vein. After the vein has been 
thoroughly cleared, an aneurysm needle is passed about the 
vessel, care being taken not to include the pneumogastric nerve 
between the ligature. Two ligatures are passed about the vein 
in this way and the vessel is divided between these ligatures. If 
the incision in the neck has not been carried completely down 
to the sheath of the vessel throughout the entire length of the 
primary incision in the first instance, it is then extended deeper 
and deeper until the vein is exposed from the point of its divi- 
sion low down in the neck to a point as close to the base 
of the skull as possible. The entire vein is then carefully dis- 
sected out, all tributary branches being divided between two 
ligatures as the dissection is continued from below upward. 
The number of tributaries requiring ligation will vary in indi- 
vidual cases. The branch which always requires ligation is the 
common trunk of the temporal and facial veins which joins the 
internal jugular at a point just about the level of the hyoid 
bone. Occasionally the thyroid and laryngeal branches must 
be divided between two ligatures as w r e proceed from below 
upward before this large trunk is reached. In many in- 
stances, however, the thyroid, laryngeal, and lingual branches 
are so small as to entirely escape observation. When the 
common trunk of the lingual, temporal, and facial is reached, 
care must be taken to separate this trunk cautiously from the 
underlying tissues and to divide it between two ligatures. In 
two of my cases I have found a clot in the internal jugular ex- 
tending down as far as the point where the facial vein joins 
the internal jugular and systemic infection was undoubtedly 
occasioned by the carrying into the general circulation of por- 
tions of this clot by the blood current entering the jugular 
through the facial and temporal veins. This large branch must 
therefore be carefullv secured and divided between two lisfa- 



57< 



SINUS THROMBOSIS. 



tures. The internal jugular is then followed upward as high as 
possible, is surrounded by two ligatures and divided between 
them. As the common trunk of the temporal and facial vein 
is the last large branch given off from the vein, it is not neces- 
sary to follow the vessel completely to the base of the skull. 
It may be divided with perfect safety at a point three quarters 
of an inch above where the facial vein enters the internal jugu- 
lar. I do not think it advisable to attempt to wash out any 
clot which may be present by the injection of fluid into the 
proximal extremity of the vein. The small segment of vessel 
lying between the point of ligation and the opening in the lat- 
eral sinus can scarcely afford any opportunity for systemic infec- 
tion. I believe there is much more danger of forcing septic 
material into the general circulation through the inferior petro- 
sal sinus if fluid is injected into the lower portion of the vein, 
than if the operation is terminated simply by a ligation of the 
vessel. After the operation has been concluded the wound in 
the neck should be flushed with a warm saline solution, and the 
margins of the wound united by means of interrupted sutures, 
preferably of silk. The upper angle of the wound should be 
left open and a packing of iodoform gauze inserted. The open- 
ing made in the sinus at the early part of the operation should 
then receive attention. An iodoform gauze packing should be 
introduced into the lumen of the sinus, the strip of gauze ex- 
tending well down toward the jugular bulb. In this way any 
systemic infection from the small portion of clot remaining in 
the vessel between the opening in the sinus and ligated ex- 
tremity of the jugular is avoided as far as possible. If there 
has been haemorrhage from the upper end of the sinus, this 
haemorrhage will have been already controlled by means of 
gauze packing. The entire mastoid wound should then be 
dressed in the usual way, care being taken to separate the mas- 
toid antrum from the open sinus by means of gauze packing. 
Out of nine cases upon which I operated for excision of the 
internal jugular, eight recovered and one died; the death was 
not due to jugular thrombosis. 



CHAPTER XXXI. 

OTITIC MENINGITIS. 

In instituting operative procedures for a meningitis, the 
rational symptoms seldom aid us in deciding upon the area 
involved, as these cases usually present themselves to the aural 
surgeon after the mastoid cells have been thoroughly obliter- 
ated and all foci of diseased bone about the middle ear removed. 
In cases which come under observation late, and where the 
mastoid has not been operated upon, this operation should con- 
stitute the initial step of the procedure. If the dura is exposed 
either by caries of the tympanic roof or of the inner table of 
the skull over the lateral sinus, any evidences of meningitis 
which may be present will be discovered at the time of the pri- 
mary operation. In the absence of any evidence of disease of 
the dura in these localities, or where the dura has not been ex- 
posed at the time of the mastoid operation and where the symp- 
toms of meningitis develop, the surgeon should do an explora- 
tory craniotomy, entering the skull just above the external 
auditory meatus. This is best done by dividing the soft parts 
by means of a curved incision from a point one half inch behind 
the posterior border of the meatus, extending it upward over 
the top of the ear to a point one inch and a half above the 
superior margin of the auricle, and then curving downward 
and forward to a point one half inch behind the external angu- 
lar process of the frontal bone. All the structures are divided 
down to the bone, bleeding points secured by means of clamps, 
and the lower flap, including the auricle, pushed downward by 
means of the periosteal elevator, so as to bare the skull through- 
out the entire extent of the cutaneous incision. If more room 
is needed, the upper flap may also be elevated by means of the 
periosteal elevator. The skull is then opened by means of the 
chisel about half an inch above and a quarter of an inch in 

(579) 



58o 



OTITIC MENINGITIS. 



front of the centre of the external auditory canal, this being- the 
thinnest part of the squamous plate, and therefore a region at 
which the cranial cavity can be most easily opened. As soon as 
the opening has been made in the skull, this opening is rapidly 
enlarged upward, backward, and downward by means of the 
rongeur forceps until the opening measures at least one inch in 
the vertical diameter and one and a quarter inches in the longi- 
tudinal diameter. The bone is removed below sufficiently to 
allow the director or a flat, narrow retractor to be passed along 
the roof of the tympanum as far almost as the apex of the 
pyramid. In some cases the finger can be introduced in place 
of either the director or narrow retractor, although this fre- 
quently is not possible, owing to adhesions. If the dura is 
found involved — and frequently this is the only condition we 
find — it is well to turn down a dural flap. In order to effect this 
a curved incision is made through the dura from in front 
upward and backward, so as to leave the dural flap attached 
below. This flap is turned down and the surface of the brain 
exposed. In cases of advanced meningitis we find the pia very 
much injected and considerable fluid in the arachnoid space. 
We find reports of a number of cases in which the mere expo- 
sure of the dura and the incision of this membrane has allowed 
the escape of a large amount of serum, and has been followed 
by complete recovery, apparently for no other reason than that 
the intracranial tension was relieved. This measure is, there- 
fore, advised by Boenninghaus.* 

Where the brain substance bulges through the dural wound, 
it is always wise to make an incision through the brain sub- 
stance into the lateral ventricle, so as to relieve any accumula- 
tion of fluid which may be present. It will be remembered, in 
speaking of serous meningitis, that one of the forms of this 
disease is characterized by an accumulation of fluid in the lateral 
ventricles. The evacuation of this fluid by incision through 
the brain substance is by no means new, having been advocated 
a number of years ago for the relief of chronic hydrocephalus 
in infants. In cases of acute serous meningitis, however, 
dependent upon a middle-ear suppuration, this procedure is 
certainly indicated as a means of relieving the intracranial 
pressure. 

In order to enter the lateral ventricle, in the region above 

* Meningitis serosa acuta, Wiesbaden, 1897, p. 65. 



LUMBAR PUNCTURE. 581 

described, either a large aspirating needle attached to a syringe, 
or, preferably, a narrow, straight knife, sharp-pointed, should 
be introduced into the brain substance, forward and inward and 
slightly upward, for a distance of about one and three quarters 
to two and one half inches. In case the ventricles are filled 
with fluid, as the result of a serous meningitis, serum will be 
obtained before the knife has entered this distance, owing to the 
fact that the cavity of the ventricle is much dilated by the pres- 
ence of the serum. If an excess of ventricular fluid is found, 
it is well to insert a strip of sterile gauze into the cavity in order 
to secure drainage. Some authors prefer to separate the mar- 
gins of the incision in the brain by means of retractors, and to 
introduce a piece of sterilized rubber tissue into the ventricle, 
so as to line it; into this pouch of rubber tissue is packed sterile 
gauze. As the ventricle resumes its normal dimensions, the 
gauze packing is crowded out from the ventricle, together with 
the rubber tissue, the incision in the brain subsequently heal- 
ing after the normal condition of the ventricle has been re- 
stored. Some authors prefer to simply remove the fluid from 
the ventricle by tapping with a large needle, instead of evacu- 
ating it by free incision. It must be admitted, however, that 
free incision and drainage is preferable to simple tapping of 
the cavity. 

Another method of treating this condition is by lumbar 
puncture, first advised by Quincke. This consists in entering 
the spinal canal either between the fourth and fifth lumbar ver- 
tebrae, or between the fifth lumbar and first sacral vertebrae. 
The procedure is not very painful, and can frequently be per- 
formed without the induction of local anaesthesia. In nervous 
patients it is wise to anaesthetize the operative field either by 
the subcutaneous injection of a few minims of a sterilized four- 
per-cent solution of cocaine, or by freezing the parts with a 
spray of ethyl chloride, commonly known as kelene. In order 
to perform this operation, the back of the patient should be 
sterilized for a distance of four inches on each side of the median 
line, from a point just below the free border of the ribs to the 
tip of the coccyx. The patient should be placed either in the 
knee-chest posture or upon the abdomen, with a large, hard 
pillow under the belly just above the anterior superior iliac 
spines, the arms of the patient hanging forward over the table. 
In this way, the lumbo-sacral muscles are put upon the stretch. 
A rather long aspirating needle, about three inches in length 



582 OTITIC MENINGITIS. 

and of a diameter of about one millimetre, is then plunged 
through the soft tissues of the back, either directly in the median 
line, or, preferably, slightly to the left of the spinous processes 
of the vertebrae, either between the fourth and fifth lumbar 
spines or between the fifth lumbar spine and the first sacral 
vertebra. If the puncture is made to the left of the median 
line, the needle should pass upward and inward to the right. If 
made directly in the median line, it should pass inward and 
slightly upward. In children, the puncture, according to 
Quincke, is easily made in the median line; in adults, it is best 
to introduce the needle about a finger's breadth to the left of 
the spinous processes of the vertebrae. There is no danger of 
injuring the spinal cord at this point, because, as will be remem- 
bered, the cord does not extend below the level of the first 
lumbar vertebra, the spinal canal in this region consisting of 
the lumbar sac, which contains the cauda equina. This opera- 
tion should only be undertaken under the most strict aseptic 
precautions, as otherwise infection of the cerebro-spinal fluid 
might easily occur. As soon as the spinal canal has been 
entered the operator will be cognizant of the fact by a flow of 
limpid or slightly turbid fluid from the canula. If a meningitis 
is present and there is increased pressure of the cerebro-spinal 
fluid, the escape of fluid from the canula will be very free. It 
is not wise, under any conditions, to draw off more than one 
hundred cubic centimetres of the fluid, and it is better not to 
draw this full amount at once, even when the pressure is high, 
but to cause the flow to intermit occasionally by closing the 
canula for a few moments, thus preventing any sudden altera- 
tion of intracranial pressure. 

As a diagnostic measure, lumbar puncture may be consid- 
ered of value. The free flow of a large amount of fluid cer- 
tainly demonstrates increased pressure either in the subdural 
space or in the ventricles. Various experiments have been 
made, notably by Schultz, Quincke, and others, as to the normal 
pressure of the spinal fluid. In the horizontal position with 
a tube whose diameter is one millimetre, Kronig states the pres- 
sure is from one hundred to one hundred and fifty millimetres 
of water; according to Quincke, the normal pressure is between 
forty and sixty millimetres of water; and according to Stradel- 
mann, the normal pressure varies from forty to one hundred and 
thirty millimetres of water. These data are simply given to- 
show how different authorities vary in what they consider the. 



EPIDURAL ABSCESS. 583 

normal pressures of the intraspinal fluid. All agree, however, 
that in a meningitis this pressure is very much increased, vary- 
ing anywhere from two hundred to six hundred millimetres of 
water. The specific gravity of the fluid withdrawn is, in serous 
meningitis, very little above the normal standard. In purulent 
meningitis, however, it rises to a point considerably above the 
normal standard. In purulent meningitis also, the spinal fluid 
contains from eight to nine per cent of albumin, against a 
normal percentage of one fiftieth of one per cent to one half 
of one per cent. 

As a diagnostic measure, therefore, lumbar puncture may 
be advised in doubtful cases. As a therapeutic measure, how- 
ever, in cases of otitic origin, it must be vastly inferior to an 
exploratory craniotomy, and evacuation of the serous product 
of the inflammation, either by incision of the meninges or of 
the brain substance itself. Therefore, it must be repeated, that 
lumbar puncture has a very limited place in otological surgery. 
As a therapeutic measure, it is of absolutely no value in this 
class of cases. 

Epidural Abscess. — When there is pus between the dura 
mater and the osseous wall of the cranium it is only necessary 
to perforate the skull in order to evacuate the fluid. The deci- 
sion as to the exact location of such an abscess must always be 
largely a matter of conjecture, and it is well to remember that, 
out of a series of cases reported, the most usual location has 
been either in the posterior or in the middle cranial fossa in the 
order named. The operative technique consists in the removal 
of the inner table of the skull, over the site of the mastoid open- 
ing, extending it as much as is necessary to expose the dura in 
the posterior fossa. A probe is then inserted between the me- 
ninges and bone and passed gently in every direction, to 
discover, if possible, the location of the purulent focus. Failing 
in this, the middle cranial fossa should be explored ; this may be 
done by enlarging the original opening by means of the ron- 
geur. Owing to the thickness of the skull in this region, it is 
wiser to perforate a second time than to enlarge the previous 
opening. For this purpose the cutaneous incision is extended, 
in the same manner as previously described under Operative 
Treatment of Otitic Meningitis. After the squama has been 
exposed, the middle cranial fossa is entered, in the manner 
already detailed, and the entire tympanic roof and extradural 
space of the middle fossa is carefully explored by means of the 



58 4 



OTITIC MENINGITIS. 



probe, in order to discover any extradural collection of pus. If 
such a collection is found, it is evacuated, and the opening in 
the skull is enlarged so as to admit of a thorough exploration 
of the cavity in every direction. It is unwise, under these cir- 
cumstances, however, to remove the bone beyond the limits of 
the abscess. We find, in these cases, that the purulent collec- 
tion is walled off from the general cranial cavity by firm adhe- 
sions between the dura and the skull. If, after evacuating the 
abscess, the surgeon persists in the removal of bone until actual 
normal dura is encountered, these adhesions are broken down 
and there is danger of infecting the previously healthy dura 
and of setting up a purulent meningitis. The line of adhesion 
should, therefore, be carefully preserved, but enough bone 
should be removed to allow the entire abscess cavity to be 
explored by means of the finger. After the pus has been evacu- 
ated, the abscess cavity should be wiped out with either sterile 
sponges or with sponges moistened in a 1-5,000 bichloride of 
mercury. If the cavity is large and the discharge thick, it may 
be well to irrigate the cavity with a warm solution of mercury, 
of a strength of 1-5,000. After this irrigation the abscess cav- 
ity is packed with iodoform gauze. The anterior portion of the 
incision through the skin is closed by means of one or two 
sutures of silkworm gut. The original mastoid wound is packed 
in the usual manner, and completely isolated from the opening 
into the cranial cavity in the middle fossa by means of a firm 
packing of iodoform gauze introduced between the packing in 
the abscess cavity and the packing in the mastoid antrum. 

The separation of the epidural abscess cavity from the mas- 
toid wound by means of firm gauze packing should be looked 
upon as a matter of great importance, not only in applying 
the dressing immediately after the operation, but also at each 
subsequent dressing, until the walls of the cavity are covered 
with healthy granulation tissue. If this is not done, infection 
of the exposed dura may occur, resulting in a general puru- 
lent meningitis. If the abscess is large, it is well to change 
the dressing every day so as to keep the surrounding tissues 
as free from pus as possible and to thus prevent the infection 
of the dura adjacent to the abscess. 

In cases in which the lateral sinus lies in the floor of the 
abscess cavity, and is covered with granulation tissue, the 
operator should not forcibly curette away these granulations. 
This tissue forms a barrier against the infection of the under- 



EPIDURAL ABSCESS. 585 

lying sinus from the pus in which it is bathed, and its forcible 
removal may be followed by infection of the sinus, and devel- 
opment of a sinus thrombosis. Careful palpation of the sinus 
with the finger will usually enable the operator to determine 
the presence of a clot in the lumen of the vessel. It is often 
wise in doubtful cases to follow the course of the sinus for a 
short distance beyond the limits of the abscess cavity, either 
in an upward or downward direction, according to the loca- 
tion of the abscess, if the size of the cavity does not expose 
the sinus for a distance of, at least, three quarters of an inch. 
Pressure should next be applied to the upper exposed portion 
of the vessel close to the bony margin of the wound. If no 
thrombus is present, pressure above will cause the vessel to 
collapse below. The pressure above should next be removed 
and the sinus compressed at the lowest point of its exposure. 
If the lumen of the vessel is free, it will immediately fill with 
blood to the point at which pressure is applied. 

If, after applying these tests, the operator is in doubt as 
to the presence of a thrombus, he may then remove the granu- 
lations from the surface of the vessel, cleanse the abscess cav- 
ity thoroughly by the gentle use of the curette, and then open 
the sinus in the manner already described on a previous page, 
for exploration of the lateral sinus in doubtful cases. If a 
thrombus is found, the condition should be dealt with in the 
manner already detailed in a previous chapter. It will be 
seen, therefore, that in no instance should granulation tissue 
over the sinus be removed until the operator has decided to 
make an exploratory opening in that vessel and to then subse- 
quently shut it off entirely from the general circulation by 
means of a firm packing of iodoform gauze. 

The results of operative treatment in epidural abscess are 
extremely favorable. The author's statistics have already 
been given on page 472. 



39 



CHAPTER XXXII. 

CEREBRAL AND CEREBELLAR ABSCESS. 

Where localizing symptoms indicative of the presence of 
a collection of pus within the brain substance are evident, the 
surgeon has then precise indications as to what portion of the 
cranial cavity shall be entered for the evacuation of this puru- 
lent collection. In most cases of cerebral abscess arising from 
suppurative otitis, however, localizing symptoms are rare. The 
surgeon is most frequently in doubt as to whether the infected 
area within the brain lies in the cerebrum or in the cere- 
bellum. In certain cases, especially where the left ear is affected, 
causing involvement of the left side of the brain, the aphasic 
symptoms enable the surgeon to make a fairly accurate diagno- 
sis. Symptoms of loss of power in the upper and lower extremi- 
ties are seldom met with. When, therefore, the right ear 
is involved, practically no definite localizing symptoms are 
present. 

As the patient presents himself, the surgeon has, then, no 
positive evidence of the location of the intracranial infection. 
He has simply the history of a suppurative process within the 
middle ear which has lasted for a considerable period of time. 
The general appearance of the patient is indicative of some 
severe constitutional infection, but an examination of the tho- 
racic and abdominal viscera show the parts to be perfectly nor- 
mal. In the more advanced cases the patients are in a state of 
hebetude or even in a state of coma. The surgeon has nothing 
whatever to guide him except the fact that there is a chronic 
suppurative otitis upon one side. All operative procedures 
must, therefore, be of an exploratory character, and the open- 
ing in the cranial cavity must be large enough to enable the 
operator to investigate the entire cranial contents rapidly. We 
know from autopsies performed upon cases of this kind which 
have terminated fatally, that the most frequent site of an ab- 

(586) 



EXPLORATORY OPERATION. 587 

scess, due to middle-ear suppuration, is in the temporo-sphe- 
noidal lobe, the infection taking place directly through the roof 
either of the mastoid antrum or of the tympanic vault. The 
second favorite site is abscess of the cerebellum, infection occur- 
ring through the posterior wall of the lateral sinus. In all 
exploratory operations upon the brain, when the primary infec- 
tion is an otitis, the first step should be to rapidly enter the mas- 
toid antrum and to expose the roof of the tympanum and of the 
mastoid antrum. The cutaneous incision should then be ex- 
tended upward and forward to the external angular process of 
the frontal bone. The lower flap is then pushed downward and 
the squama uncovered. It is not wise to elevate the periosteum 
of the upper flap unless it is found subsequently that a larger 
opening in the cranial cavity is necessary. The mastoid wound 
having been packed with gauze, the surgeon then enters the 
cranial cavity at a point just above the external auditory mea- 
tus. The squama is extremely thin in this region, and the wall 
of the skull is easily broken through by a few strokes of the 
chisel. This opening should be enlarged in every direction by 
means of the rongeur forceps, the aperture being gradually 
extended upward and backward until an opening at least an 
inch in diameter has been made. A probe or director is then 
cautiously introduced betweeen the dura and the upper surface 
of the petrous pyramid. If care is taken, the dura may be sepa- 
rated from the superior surface of the pyramid and the finger 
passed along its bony surface. If the dura appears normal 
through the opening already made, it is then wise to continue 
this opening downward and backward by removing the floor 
of the middle fossa over the region of the tegmen tympani and 
tegmen antri. This exposes the lower surface of the temporo- 
sphenoidal lobe. If, when the mastoid was opened an opening 
was discovered by means of the probe either through the teg- 
men tympani or the tegmen antri, the surgeon will naturally 
rapidly enlarge the exploratory opening in the cranium by 
removal of the tegmen tympani and tegmen antri by means of 
the rongeur forceps, thus making the exploratory opening con- 
tinuous with the external auditory meatus and the vault of the 
tympanum. In this way, an exceedingly large dural area is 
exposed, and in that region where infection is most likely to 
occur. It is seldom that either inspection or palpation of the 
dura will give any indication as to the location of the abscess. 
Where a softened dural area is found, the surgeon naturally 



588 CEREBRAL AND CEREBELLAR ABSCESS. 

would make an incision through the dura and enter the brain 
substance at this point in the hope of evacuating the pus. If 
no such indication is present, however, the next point is to 
reflect a dural flap before incising the brain substance. I am 
strongly averse to making incisions into the cerebral substance 
before reflecting a dural flap, although I know that this is the 
practice of many eminent surgeons. The dural flap is best 
formed by making a curvilinear incision through the dura, the 
convexity of the flap being downward, corresponding approxi- 
mately to the linea temporalis. This flap is reflected upward 
and the knife is then plunged into the brain substance,, first in 
a direction upward, backward, and inward. If this puncture is 
followed by a discharge of pus along the blade of the knife, 
a free incision is made into the brain substance, care being taken 
that the knife follow along the line of a convolution, rather than 
across it, in order to avoid the wounding of important vessels 
which may give rise to troublesome haemorrhage. For the 
same reason, the knife should always be plunged into the con- 
vexity of a convolution and not into the fissure between the 
two convolutions. It most frequently happens that the first 
incision will fail to reveal the presence of pus. The surgeon 
must then carefully introduce the knife in various directions, 
downward, forward, and inward; downward, backward, and 
inward; and upward, forward, and inward; he should not be 
satisfied to rely upon puncture alone, but should incise the 
brain substance thoughout the entire depth of the puncture 
for a distance of at least half an inch. It sometimes happens 
that the pus from the cerebral abscess is so thick it will not 
flow along the knife unless a rather free incision is made, and 
although the abscess cavity may have been entered by an 
exploring instrument, the presence of pus will be unrecognized 
unless the incision is sufficiently extensive to allow of the evacu- 
ation of the thick, broken-down cerebral substance, which 
makes up the contents of the abscess. It is also wise, in case 
an incision in various directions does not reveal pus, to cau- 
tiously introduce a grooved director along the line of incision in 
the hope that a pent-up collection of pus deep in the cerebral 
substance may be recognized by the escape of pus along the 
groove in the director. As soon as the abscess cavity has been 
entered and pus flows freely from the incision in the brain sub- 
stance, the little finger should be cautiously introduced into 
the abscess cavity and moved gently about so as to thoroughly 



IRRIGATION. 589 

break clown all necrotic cerebral substance and favor its free 
discharge. Some advise the introduction of a pair of dressing 
forceps along the line of incision, separating their blades, and 
thus effecting the free evacuation of the contents of the abscess. 
While this plan may be followed, it seems to me that the intro- 
duction of any instrument into the cerebral substance is fraught 
with more danger than is the insertion of the trained finger of 
the operator. The finger cautiously introduced into a brain 
abscess easily recognizes the difference between healthy and 
diseased tissue. With the tip of the finger the necrotic tissue 
can be gently broken down until the wall of the abscess is felt 
to be fairly firm. After an abscess has been completely evacu- 
ated it is best to pack the cavity either with iodoform gauze or 
sterile gauze. . If the abscess is exceedingly foul and there is 
considerable necrotic tissue, I am in favor of packing the entire 
cavity with iodoform gauze. 

As a rule, I do not think it wise to irrigate a cerebral abscess 
at the time of primary operation. I can easily conceive of some 
cases in which irrigation may be advisable. I think, however, 
that the introduction of fluid at the time of primary operation 
is rather a disadvantage. It is true that by free irrigation much 
of the necrotic tissue within the abscess cavity may be washed 
away. This necrotic tissue, however, will be expelled equally 
well by the intracranial pressure in the course of twenty-four 
hours if the abscess cavity is filled by a fairly firm gauze packing. 
It has always seemed to me that in washing out the cavity of 
a brain abscess at the time of primary operation there was 
danger of washing away some of the healthy brain tissue which 
might be exposed or of infecting the deeper parts through the 
current of fluid introduced. If great care is exercised, this 
objection would hardly hold. Whenever irrigation is practised 
the fluid should be introduced through a small canula at low 
pressure, while the avenue for the return current should be 
large. Experience, however, teaches us that necrotic tissue is 
quite well expelled in the course of a few hours by the intra- 
cerebral pressure, and, on general principles, it seems wise to 
interfere as little as possible with the brain substance. 

Quite recently, Dr. Whiting, of this city, has perfected an 
instrument known as the encephaloscope, by which a clear view 
of the interior of a brain abscess can be obtained. This instru- 
ment is an ear speculum of large size, the lumen of which is 
completely filled by an obturator. The end of the obturator is 



590 



CEREBRAL AND CEREBELLAR ABSCESS. 



rounded, so as to admit of the introduction of the speculum, 
without injuring the delicate brain tissue. After the abscess 
cavity has been opened, the encephaloscope, with the obturator 
in position, is cautiously introduced into the incision, and the 
obturator withdrawn. By the aid of reflected light the surgeon 
can then inspect the entire abscess cavity, and can also see to 
thoroughly cleanse this cavity under ocular inspection. If mul- 
tiple abscess is present, he will be able to discover that the 
primary incision has not caused a complete evacuation of all 
the pus within the brain, and will, in some instances, be able 




FlG. 157. — Whiting's encephaloscope : A, Instrument ready for introduction ; ob- 
turator is in position and the handle is attached to the speculum. B, Obturator, 
speculum, and handle separated. 



to open up these other foci of infection under direct inspec- 
tion. The packing of the abscess cavity is much facilitated by 
the use of this instrument. Dr. Whiting reports four cases of 
temporo-sphenoidal abscess operated upon successfully, and 
attributes his success in no small degree to the use of this 
device. 

After an abscess has been evacuated and the gauze packing 
introduced, care should be taken to isolate the adjacent brain 
substance and the meninges from the abscess cavity by means 
of gauze packing. The middle ear and antrum should also be 
packed off separately to prevent any infection of healthy brain 
tissue which may lie immediately adjacent to infected areas 
within the middle ear. The anterior angle of the wound should 



PACKING OF WOUND. 591 

be closed with sutures, either of silkworm-gut or of strong 
silk, to prevent scarring as far as possible. The entire opera- 
tive field is then covered with the usual antiseptic dressing and 
a bandage applied. The first dressing should be made about 
twenty-four hours after the operation. At this dressing I think 
it wise to remove the gauze packing from the abscess cavity, 
and to again introduce the finger into the abscess. The removal 
of the finger is usually followed by the discharge of consider- 
able pus, although, apparently, the packing has filled every 
recess within the abscess cavity. I think that the introduction 
of the finger at the first and subsequent dressings, for a period 
of at least a week or ten days after the operation, is of impor- 
tance to avoid the possibility of the forming of secondary small 
abscesses in the immediate proximity of the site of primary 
cerebral infection. This introduction of the finger is, of course, 
somewhat painful, but causes far less suffering than would be 
imagined. If the abscess is large and deep-seated, I have found 
it wise at the first dressing to substitute the rubber drainage 
tubes for the gauze packing. I usually introduce two tubes into 
the cavity side by side, and assure myself that the tubes are 
patent when in position by irrigating the cavity gently with a 
warm saline solution. The wound is then packed in the manner 
indicated and described in the primary operation. Where the 
discharge from the abscess is foul, it is usually wise to dress 
the case every twenty-four hours for a period of ten days after 
the operation, at the end of which time the dressing may be 
made less frequently. 

Considerable latitude of opinion exists as to the method of 
dressing these cases. Some recommend lining the entire cavity 
with perforated rubber tissue and packing the cul-de-sac thus 
formed with either sterile or iodoform gauze. Others intro- 
duce wicks of gauze saturated with either iodoform or a mix- 
ture of boric acid and iodoform. If the surgeon is perfectly 
certain that the abscess cavity has been rendered thoroughly 
sterile, it is quite permissible, as Macewen states, to remove all 
drainage tubes at the end of twenty-four to forty-eight hours, 
and to allow the walls of the abscess to come together. If the 
surgeon does not care to do this, an absorbable bone drainage 
tube may be inserted, thus keeping up drainage for a few days, 
and as the tube is absorbed the walls of the abscess cavity come 
together and the parts return to their normal condition. 

In dealing with abscesses of otitic origin, however, it seems 



592 



CEREBRAL AND CEREBELLAR ABSCESS. 



to me that the surgeon runs considerable risk in assuming that 
the entire abscess cavity has been rendered aseptic, and it is cer- 
tainly wiser, in the majority of cases, to keep the drainage tube 
in position for a sufficient length of time to be perfectly cer- 
tain that all infectious material has been evacuated from the 
cerebral substance. Where an abscess has been evacuated, the 
edges of the dural flap should not be approximated, as such a 
procedure would favor the retention of pus either within the 
abscess cavity, or infection of the arachnoid space. This latter 
accident should be guarded against by the use of a firm extra- 
dural packing along the margins of the dural opening so as to 
cause adhesion between the dura and pia mater in the neigh- 
borhood of the abscess, thus obliterating the subdural space 
over this area. Where an exploratory operation has been per- 
formed and no pus has been evacuated, the margins of the 
dural wound should be brought together by very fine inter- 
rupted catgut sutures, so as to prevent the protrusion of the 
brain substance through the opening. In these cases, also, the 
incision for exposure of the squamous plate may be entirely 
closed by means of sutures, a thin strip of gauze or of folded 
rubber tissue being introduced between the soft parts and the 
exposed dura to afford drainage to any serum which may exude 
during the first few hours. This drain should be removed at 
the time of the first dressing, which need not be made for five or 
six days after the exploratory operation, unless symptoms arise, 
such as elevation of temperature or local pain, calling for a 
change of dressing. 

If one of the lateral ventricles is entered in making an 
exploratory incision, ventricular fluid must be evacuated, and 
as in all intracranial diseases attended with venous hypersemia 
the ventricular fluid is increased in amount, the liberation of this 
fluid is certainly of therapeutic value. If the ventricle con- 
tains simply an abnormal amount of clear serum, this should be 
evacuated and the cavity of the ventricle either packed lightly 
with sterile gauze, or lined with sterile rubber tissue as above 
described. In either case, great care must be taken to prevent 
infection of the ventricular fluid. We should also remember 
that a cerebral abscess may rupture into the ventricles, and these 
cavities must be opened and drained in order to secure the 
desired end. 

In order to explore the cerebellum for a suspected abscess, 
the soft parts covering the skull should be divided by an incision 



EXPLORATION OF CEREBELLUM. 



593 



extending from the upper border of the auricle horizontally 
backward to the occipital protuberance. As the otologist has 
to do entirely with those cases dependent upon middle-ear sup- 
puration, the previous mastoid incision will have already been 
made. To explore the cerebellum, therefore, it is only neces- 
sary to make an incision from the upper angle of the ordinary 
mastoid incision backward to the occipital protuberance. A 
triangular flap, with base downward, is thus formed. This tri- 
angular flap is reflected downward, the soft tissues being dis- 
sected from the underlying bone. In reflecting this triangular 
flap it is wise not to remove the periosteum, the soft parts being 
rapidly dissected upward down to the periosteum. 

The site of election for an exploratory opening into the 
cranial cavity for a suspected cerebellar abscess, lies at a point 
one and one half inches behind the centre of the external 
auditory meatus, and at a point one quarter of an inch below 
the horizontal plane passing through the centre of the external 
auditory canal. For practical purposes, it is necessary for the 
surgeon to remember that the cranial cavity may be opened at 
a point an inch and a half behind the centre of the meatus just 
below the level of the occipital protuberance. After the 
exposure of the surface of the skull, in the manner already 
described, the periosteum should be incised at the point of 
election for perforating the bone. The cerebellar cavity is 
best entered by means of the chisel or gouge. The bone is 
very thin in this region, and a few strokes of the chisel are suffi- 
cient to break down the bony wall. The opening into the cere- 
bellar fossa is then enlarged by means of the rongeur forceps. 

After the cerebellar dura has been exposed, a dural flap 
should be made and the cerebellar substance exposed. A nar- 
row, straight knife is then introduced into the cerebellum, at 
first horizontally inward, then upward and inward, forward and 
inward, and, lastly, backward and inward, in order to evacuate 
any collection of pus which may be present. The depth to 
which the cerebellum may be punctured will naturally vary with 
the exact site at which it is exposed, and will also vary with 
the age of the patient. In adults, with a cerebellum exposed at 
the site of election, the brain substance may be punctured with 
safety for a depth of three quarters of an inch in every direction. 
If the puncture is carried too deeply, it is apt to open the 
fourth ventricle. As soon as pus follows an incision in the 
brain substance, the opening should be enlarged by free incision. 



594 



CEREBRAL AND CEREBELLAR ABSCESS. 



The operator may then either introduce his finger into the 
abscess cavity, or, if he prefers, may introduce the encephalo- 
scope and inspect the entire interior of the cavity. The abscess 
cavity may or may not be irrigated, according to the individual 
choice of the operator. Personally, I prefer to cleanse the cav- 
ity by means of gauze or cotton mops and not to irrigate at 
the time of operation. After the abscess cavity has been thor- 
oughly cleansed, it is lightly packed with sterile gauze, or it 
may be dressed in any of the ways detailed in the consideration 
of the treatment of cerebral abscess. 



SECTION V. 

DISEASES OF THE PERCEPTIVE MECHANISM. 



DISEASES OF 
THE PERCEPTIVE MECHANISM. 



The sound-perceiving- apparatus includes the medullary 
nuclei of the auditory nerve, and the nerve fibres joining 
these to the cortical areas in the first and second temporal 
convolutions. Passing from the medullary centres in the oppo- 
site direction, it includes the trunk of the auditory nerve and 
its terminal filaments specialized in the labyrinth for sound 
perception. 

In addition to the perception of sound, the auditory nerve 
trunk contains a distinct group of fibres which preside over 
the equilibrium of the body. The terminal filaments of these 
fibres are distributed to the semicircular canals, while their 
cortical areas within the cranium are found within the cere- 
bellum. Interference with the perceptive mechanism is con- 
sequently attended in most instances by some disturbance of 
equilibrium. This may be so slight as to entirely escape the 
notice of the patient unless his attention is particularly drawn 
to it, or it may be the principal disorder for which he seeks 
relief. Interference either with equilibrium or with the func- 
tion of audition, characterized by an impairment in this func- 
tion or its perversion, may depend upon organic changes in 
any portion of the mechanism specialized for this particular 
purpose. It may be also of reflex origin, no structural change 
having taken place in any portion of the ear, but an affection 
of some remote organ influencing by reflex action this par- 
ticular part of the economy. 

It follows, therefore, that the history of the individual is 
of particular importance in connection with diseases of this 
portion of the auditory apparatus. Some illness in early life, 
or a slight traumatism, might entirely escape the mind of the 
patient, as having no bearing upon the condition for which he 
seeks advice, but may often lead us to a correct interpretation 

(597) 






598 DISEASES OF THE PERCEPTIVE MECHANISM. 

of the cause of a symptom. The physical examination of the 
ear is really a very small part of the investigation in these 
cases, and one who confines himself to this special examina- 
tion alone must invariably fall into error in his attempts to cor- 
rectly explain the cause of many of the symptoms. Certain 
phenomena are characteristic of involvement of this portion 
of the organ of hearing. The hearing power, in cases where 
the perceptive mechanism is principally involved, is either 
profoundly affected or but slightly changed, the moderate 
grades of impairment depending usually upon diseases of the 
conducting apparatus. Tinnitus is almost always present, 
and, if carefully investigated, we shall usually find a history 
of attacks of vertigo. I am of the opinion that sufficient stress 
is never laid upon the symptoms dependent on labyrinthine 
involvement in the ordinary cases of diseases of the conduct- 
ing apparatus. A secondary labyrinthine disturbance may 
occur as a complication or as a sequel of changes within the 
middle ear, and yet of itself require no treatment other than 
that directed to the tympanum. This latter fact does not 
make it less a labyrinthine affection, the removal of the cause 
being the rational method for overcoming this disturbance. 

With reference to the impairment of hearing, low-pitched 
sounds are perceived better than those of high pitch, particu- 
larly if a preceding disease of the middle ear has led to the 
involvement of the nervous apparatus. Marked variations 
in the degree of impairment, dependent upon climatic changes 
or mental or physical fatigue, are quite as characteristic of a 
pathological condition located here as they are of middle-ear 
changes. 

Where the power of audition changes with the weather, 
being worse on damp days and improving as the atmosphere 
clears, it is usually supposed that the disturbance depends 
upon a middle-ear affection. If we remember the intimate 
relation between the venous circulation within the turbinated 
bodies and the venous return current from the cochlea, we 
can easily understand how a turgescence of the nasal mucous 
membrane will cause a venous stasis within the labyrinth. 
No better proof can be afforded that this is the case than the 
marked relief to subjective noises often observed when the 
turbinated tissues are exsanguinated by the use of cocaine. 

The duration of the affection and its progress also aid us 
in determining its site. Primary lesions of the perceptive 



GENERAL OBSERVATIONS. 



599 



apparatus either remain quiescent or improve to a certain 
extent spontaneously as time progresses, excepting, of course, 
those dependent upon a specific inflammation. Secondary 
changes within the receptive apparatus, organic in character, 
are usually due to some chronic affection of the middle ear 
either of the same or opposite side. When the opposite or- 
gan is primarily affected the impairment of function advances 
rapidly, as a rule, and here the history of previous tympanic 
disease renders diagnosis clear. The character of the subjec- 
tive noises is of aid in locating the lesion, in that the particu- 
lar character of the sound points to the special part of the 
labyrinth involved. Almost invariably in the secondary laby- 
rinthine changes due to chronic suppurative or nonsuppura- 
tive otitis media the subjective noises are high-pitched in char- 
acter, and assume a deeper quality only after they have per- 
sisted for a long period. The complete cessation of tinnitus 
in these secondary cases probably indicates that the laby- 
rinthine invasion has ceased to progress, and the length of 
time during which the patient has been free from subjective 
noises is of aid in determining the probability of restoring 
the parts to their normal condition by treatment. Vertigo, if 
severe, points to a sudden and considerable disturbance with- 
in the perceptive mechanism, as at the onset of an attack, or 
to an aggravation of an existing condition. Repeated attacks 
of giddiness of a mild character would indicate that at these 
periods the labyrinthine structures or the higher centres 
were subjected to some unusual stimulation either from the 
tympanum, from intracranial changes, or of a reflex character 
from some visceral derangement. The effect of continued 
stimulation of the nervous mechanism by sonorous vibrations 
— as when the patient is subjected to the noise of a railway 
train for a number of hours, or has taxed himself to the ut- 
most in listening to conversation which it has been difficult 
for him to hear — is of value in diagnosis. Prolonged excita- 
tion of any nerve, at length renders it less susceptible to the 
particular stimulus which has fatigued it. When the nerve 
structures are in an abnormal condition they become fatigued 
more easily than when in a state of health ; and a patient will 
often be found to be more deaf after a prolonged railway jour- 
ney than when he has been comparatively quiet. Physical 
fatigue may indirectly bring about the same result. It is 
sometimes said that the paracusis Willisii is characteristic of 



600 DISEASES OF THE PERCEPTIVE MECHANISM. 

involvement of the nervous apparatus. This may be true 
when the patient is subjected to a noise for a short time ; but 
if the stimulation is continued, the nerve becomes fatigued 
and less responsive to stimuli. The reverse takes place when 
the nerves preserve their integrity and the conducting mech- 
anism is at fault. 

The determination of the special part of the perceptive 
mechanism involved must remain a matter of doubt in a cer- 
tain proportion of cases. In general, it may be said that the 
history of a previous middle-ear affection, of an acute infec- 
tious disease, or of a traumatism with a slight impairment of 
hearing, points to an involvement of the labyrinth. On the 
other hand, where we have symptoms referable to the ear 
in cases giving a history of severe injury followed by an 
involvement of the intracranial structures, as evidenced by 
other 'symptoms, or where there are other manifestations of 
cerebral disturbance at the time of the examination — such as 
local paralysis, psychic phenomena, etc. — we should suppose 
that the auditory cortical centres had suffered. An affection 
of the trunk of the nerve should be suspected when the im- 
pairment is to an extent uniform, or affects particularly the 
perception of those sounds to which the ear is most frequently 
subjected, since, when all the fibres of the trunk are involved, 
the fibres which are most constantly used will be most seri- 
ously affected. Marked variations in sound perception de^ 
pendent upon excitement, fatigue, disturbance of the prima 
viae, etc., would characterize the aural affection as reflex. 
Bearing these various points in mind, we should always se- 
cure the general history in every case of aural disease, so a? 
to obtain data which will yield the desired information. 



CHAPTER XXXIII. 

ANvEMIA OF THE LABYRINTH. 

^Etiology.— The condition may depend upon profuse gen- 
eral haemorrhage, either from traumatism, from the rupture 
of an aneurism, from uterine haemorrhage at childbirth, or 
may be the result of simple or pernicious anaemia. The 
changes which take place are due to the impoverished qual- 
ity of the blood with which the tissues are supplied, the lack 
of nutrition perverting their function and rendering them 
less capable of carrying out the purposes for which they 
were designed. 

Symptomatology. — When the labyrinthine structures suffer 
in this manner we find the power of audition impaired, par- 
ticularly for sharp sounds and musical notes of a high pitch. 
The involvement of the auditory function is similar in char- 
acter to the disturbance which is noticed in every part of 
the body. When nutrition is imperfect no organ performs 
its work properly. When the labyrinth suffers from mal- 
nutrition the patient seems listless and inattentive, and it 
requires a certain effort upon his part to hear what is said. 
When engaged in dialogue the hearing may not seem to be 
much affected, but when several are speaking at once he is 
unable to follow accurately the course of the conversation. 
Subjective noises are distressing, and are usually worse upon 
lying down, depending upon the adynamic condition of the 
circulatory system. The character of the subjective sounds 
is usually dull and low-pitched, synchronous with cardiac 
pulsations, and is apparently identical with the venous bruit 
heard over the great vessels of the neck in many cases of 
anaemia. Attacks of vertigo seldom occur spontaneously, but 
result from apparently slight causes, a sudden fright being 
.sufficient many times to induce an attack of syncope, while 
the same condition may follow an insignificant degree of pain 
or some slight visceral disturbance. The facies of the patient 
is somewhat characteristic, in that it appears dull, abstracted, 
40 (601) 



602 ANEMIA OF THE LABYRINTH. 

and inattentive. The other symptoms presented are those 
common to simple anaemia, and bear no relation to the por- 
tion of the body now under discussion. 

Diagnosis. — The pallor of the skin found after an acute 
haemorrhage, or the peculiar ashy-gray color met with in 
cases of simple or pernicious anaemia, should always attract 
attention. The variation in color from the normal standard 
is frequently better observed in the mucous membranes than 
in the cutaneous surface of the body. These may appear 
blanched, although the face is not sufficiently pallid to excite 
attention. 

A. Physical Examination. — In cases of simple anaemia, ex- 
amination with the otoscope reveals nothing characteristic of 
the affection, and, unless the middle ear is involved, the in- 
spection is entirely negative. 

B. Functional Examination. — The lower tone limit is nor- 
mal ; the upper tone limit may be normal or reduced ; bone 
conduction is almost always reduced to a marked degree. 
The perception of whispered or spoken words is somewhat 
reduced, although it may be nearly normal. It will be no- 
ticed that the words are repeated in an uncertain manner and 
slowly, as though it took the patient some time to compre- 
hend exactly what had been said. This is due to inco-ordina- 
tion in the receptive mechanism, the different portions failing 
to act in harmony. Perception for high sounds, as the tick 
of the watch or the click of the acoumeter, is usually more 
reduced relatively than for vocal sounds. 

The essential points upon which the diagnosis is made are : 

First, the absence of any middle-ear lesion. 

Second, preservation of the normal tone limits (or reduc- 
tion of upper limit). 

Third, marked impairment of bone conduction. 

Fourth, the anaemic appearance of the patient. 

Prognosis. — In acute cases depending upon haemorrhage, 
or in cases of simple anaemia, the prognosis is always favor- 
able. In pernicious anaemia, extravasations within the nerve 
tissues may have taken place, producing permanent structural 
changes. 

Treatment. — Certain drugs, such as iron in full doses, or 
arsenic, either in the form of arsenious acid, Fowler's solution 
or Pierson's solution, etc., should be administered for the pur- 
pose of improving the quality of the blood. The exhibition 



TREATMENT. 



603 



of cardiac stimulants is also advisable to relieve the venous 
congestion within the labyrinth. Strychnine fulfills this end, 
and at the same time exerts a beneficial effect upon the nerv- 
ous tissues themselves. This may be given simultaneously 
with ferruginous preparations, and should be administered in 
full doses. The diet should be liberal, and of such character 
as to improve the quality of the blood. The exhibition of 
alcohol in any quantity is not advisable, excepting in acute 
cases, or possibly to the extent of a little red wine at dinner. 
Quinine is particularly contraindicated in this condition. It 
is true, that many cases improve temporarily when this drug 
is administered ; but it is equally true that they almost invari- 
ably suffer from a relapse, and that the symptoms are more 
marked than those which characterized the primary attack. 
The temporary engorgement which this drug induces in the 
labyrinthine vessels often leads to permanent changes of a 
haemorrhagic nature. The temporary relief gained is due to 
the increased vascularity which the drug causes, and not to 
correction of the condition upon which the symptoms depend. 



CHAPTER XXXIV. 

HYPEREMIA OF THE LABYRINTH. 

Etiology. — An increased quantity of blood within the 
labyrinth may depend either upon a venous stasis from me- 
chanical obstruction to the return current, or upon an in- 
creased quantity of arterial blood conveyed to the part. The 
condition is prone to occur in individuals of a full habit, and 
particularly in those who are the victims of a gouty or rheu- 
matic diathesis. Those whose vocation in life demands con- 
siderable physical activity or exposure to inclement weather 
are frequently victims of this condition. Sudden physical ex- 
ertion is productive of these circulatory changes, especially in 
athletes. Overindulgence in alcohol, by increasing the force of 
cardiac svstole, leads to distention of the labyrinthine vessels. 
Risriditv in the arterial system, bv diminishing the elasticity 
of the vessels, increases relatively the pressure within the ar- 
teries. Sudden diminution in atmospheric pressure, as when 
one ascends to a great height, subjects the efferent vessels to 
the full force of the cardiac systole, and hence augments the 
blood passing through them. The prolonged action of any 
one sound also produces hypersemia, either mechanically or 
from over-stimulation, as is observed in telephone operatives, 
boiler-makers, etc. Condensation of the air in the meatus, 
from a blow on the ear or from an explosion, forces the 
stapes suddenly inward to an abnormal distance, and may 
cause hypersemia of the labyrinth. It is probable that cases 
of mild labyrinthine concussion are of this nature. 

Among those causes which lead to a venous stasis we may 
enumerate mechanical obstruction to the great vessels of the 
neck, such as pressure from a tumor or the sudden lowering 
of the head, the venous flow being then retarded by the force 
of gravitation. A severe attack of coughing, bv increasing 
the pressure within the thorax, temporarily obstructs the pas- 
sage of the blood into the right auricle and dams back the 

(6o 4 ) 



PATHOLOGY— SYMPTOMATOLOGY. 



605 



entire venous circulation. Efforts at sneezing, blowing the 
nose, etc., exert the same influence. 

Pathology. — The overdistention of the blood vessels pro- 
duces but few changes so long as their walls are in a state of 
perfect health ; when continued for a long time, localized dila- 
tation takes place, causing an irregularity in the blood supply. 
Where the pressure changes are sudden, or where the walls 
of the vessels are diseased, they may rupture and produce 
apoplectic changes. A venous hyperaemia is more prone to 
become permanent on account of the tenuity of the vessel 
walls. The labyrinthine veins are to a great extent inclosed 
in bony channels, for the purpose of avoiding this condition. 
Their exposed portions, however, suffer when an obstruction 
to the venous circulation persists for a considerable period ; 
the vessels become tortuous and dilated, and there is a transu- 
dation of serum into the labyrinthine cavity. Both the venous 
dilatation and the serous transudation increase labyrinthine 
pressure. The ultimate changes which take place in laby- 
rinthine apoplexy do not differ from those occurring in a 
similar condition in other parts of the body. The effused 
blood may be absorbed, or the affected area may undergo 
disintegration. 

Symptomatology. — Such an augmentation in labyrinthine 
blood supply is characterized by a feeling of fullness and dis- 
tention in the head, slight giddiness or even vertigo, and the 
presence of subjective noises, usually of high-pitched char- 
acter. The impairment in hearing is slight, unless the vessel 
walls suffer ; then it may be profound or even absolute, the 
accompanying giddiness being usually severe, and the tinnitus 
at first almost unbearable. Occurring as a chronic condition 
in a patient of full habit, we find these symptoms produced 
by any slight exciting cause, such as fright, rage, sudden ex- 
ertion, indigestion, too free indulgence in stimulants, etc. 

Diagnosis. — Physical examination yields no information be- 
yond showing an increased vascularity in the drum mem- 
brane and the deeper parts of the canal, causing the vessels 
to be more distinctly visible than normal. Where the mem- 
brana tympani is thin, a similar condition is often observed in 
the mucous membrane of the promontory. 

Functional Examination. — The lower tone limit is exceed- 
ingly well preserved ; the upper tone limit is usually reduced ; 
bone conduction is diminished, and the power of audition for 



606 HYPEREMIA OF THE LABYRINTH. 

vocal sounds but slightly impaired. For sharp sounds, such 
as those of the acoumeter or watch, a condition of hyperacu- 
sis may be present, and very sharp sounds are often painful ; 
or the auditory impression may persist for some time after 
the source of sound has been removed. The diagnosis in 
chronic cases will be rendered more easy if attention is di- 
rected to the increased vascularity of the integument of the 
face and the prominence of the smaller vessels beneath the 
skin, which is a fair index of the condition of the circulatory 
system within the labyrinth. The history of severe physical 
exertion or of a gouty or rheumatic diathesis also materially 
aid us in arriving at a correct opinion. 

Prognosis. — Where but slight impairment of hearing is 
present, we may hope, in recent cases, to effect an absorption 
of the effused serum and a return of the parts to a condition 
of integrity. Where the condition is of long standing, the 
outlook is more unfavorable, and the same is true where the 
changes are of hasmorrhagic nature, if the extravasation is of 
considerable size. In chronic cases it is seldom possible to 
remove the condition entirely, although much relief may be 
secured by carefully regulating the habits of life. 

Treatment. — In severe cases local depletion is a most im- 
portant measure to be adopted. Considerable blood should 
be abstracted from the mastoid region bv means of the wet 
cup. General bloodletting is permissible when the attack is 
of unusual severity. Free catharsis should be effected bv the 
administration of saline purgatives, and free diuresis should 
also be obtained. In acute cases it is well to protect the 
ear from the action of sound by occluding the meatus with 
cotton. The application of counterirritants to the mastoid 
in the form of blisters is advocated by some, but is of more 
value where the condition has continued for some time than 
immediately after an exacerbation. The use of counterirri- 
tation for a long period by means of the tincture of iodine 
applied to the mastoid region is of some value in the older 
cases, since the effusion of serum within the labvrinthine 
chamber implies an increase in pressure. The use of pilo- 
carpine is of benefit, and we should always resort to it if 
prompt relief does not follow the abstraction of blood. In 
administering this drug, it is convenient to employ a four- 
per-cent solution, as in this way the dose can be gradually 
increased according to indications. The initial dose for an 



TREATMENT. 



607 



adult is from one sixth to one eighth of a grain twice or three 
times daily. It is not necessary to confine the patients to the 
house to the extent of interfering with their daily vocations in 
carrying out the treatment. It is only necessary that for about 
two hours after each dose the patient should guard against 
draughts. This is secured if one dose of the drug is taken 
immediately upon rising in the morning, when the effect will 
have passed sufficiently before the patient is obliged to go out 
to his daily work, while the second may be taken upon re- 
tiring. The quantity administered should be just sufficient 
to increase the salivary or cutaneous secretions slightly, but 
a profound effect is undesirable. The patient should be di- 
rected to increase the dose, so that the physiological action 
is noticed after each ingestion, as otherwise tolerance is soon 
established and the full benefit to be derived is not obtained. 
It is also of great value in instances which come under treat- 
ment only after a considerable interval has elapsed since an 
acute attack, the reduction in pressure frequently being fol- 
lowed by relief. This is probably due to the absorption of 
the effusion. Iodide of potassium internally, in doses of ten 
grains three or four times daily, may be given for the same 
purpose, but is usually less efficacious. Next to the treatment 
of an acute attack, the most important measures are those of 
a prophylactic nature. Severe and sudden physical exertion 
should be enjoined. Alcohol should be interdicted, and the 
diet should be so regulated as to diminish the general pleth- 
ora. The influence of a gouty or rheumatic taint should 
never be forgotten, and the prolonged use of some alkaline 
waters, preferably those containing lithium, is of great value. 
Attention to these matters not only tends to relieve the 
chronic congestion, but also renders the patient less liable to 
an apoplectiform lesion. 



CHAPTER XXXV. 

LABYRINTHINE HEMORRHAGE. 

JEtiology. — The cause of a rupture of the walls of the 
labyrinthine vessels, with an extravasation of their contents 
into the delicate structures which the cavity contains, may be 
due to external violence, such as a blow upon the head or a 
fall from a height, or the sudden action of a loud sound, such 
as an explosion. It may be caused by manipulative proce- 
dures directed toward the relief of some middle-ear condition, 
as a forcible inflation by means of the catheter or Politzer 
bag, or severe efforts at coughing or sneezing. Mobilization 
or removal of the stapes may also produce the condition 
under discussion. 

Various conditions of the blood itself — such as that found 
in the hemorrhagic diathesis, in pernicious anaemia, and in 
leucaemia, or fragility of the walls of the blood vessels met 
with in patients of advanced years, especially those who are 
victims of a gouty diathesis — may determine the same result. 
The same accident may take place from sudden venous con- 
gestion of the head, as produced when one remains with the 
head bent forward for a considerable time, or when the ve- 
nous blood is prevented from entering the right auricle by 
holding the breath, as in swimming under water or in diving. 
Necessarily the condition may be met with as a complicating 
lesion of cerebral hyperaemia. 

Pathology. — The effusion of blood into the tissues pro- 
duces the same changes here as a similar lesion in other 
parts of the body. Where the haemorrhage is considerable, 
complete disorganization of the parts may take place from 
pressure, and a return to the normal condition becomes im- 
possible even if the effused blood is subsequently absorbed. 
In other cases the traumatism is not so great, and the struc- 
tures pressed upon simply suffer from a mechanical interfer- 
ence with the performance of their function without under- 

(608) 



SYMPTOMATOLOGY— DIAGNOSIS. 



609 



going degeneration ; this is always produced by increased 
labyrinthine pressure, when the equilibrium is restored only 
after a considerable period. The clot itself may remain and 
become organized, or may be completely absorbed or undergo 
fibrous or calcareous degeneration. According to the amount 
of original damage, the function of the part is either entirely 
destroyed or partially or completely restored. 

Symptomatology. — When a labyrinthine apoplexy occurs, 
the patient is usually seized with giddiness so severe as to 
cause him to fall unless he obtains some artificial support ; at 
the same time there is intense nausea, severe tinnitus, and a 
very high degree of impairment of hearing, or absolute deaf- 
ness. Unconsciousness may occur if the attack is severe. 
When it follows chronic labyrinthine hypersemia, certain pre- 
monitory signs often manifest themselves, such as a feeling of 
fullness and distention in the head, a throbbing within the 
ears, the cardiac impulses being not only heard, but appar- 
ently felt deep in the head. The unsteadiness of gait and 
impairment of hearing usually disappear after a few days or 
weeks, the former completely, and the latter to a marked 
degree, although the hearing does not become normal. The 
subjective noises persist, and may even increase in severity. 
Occasionally a condition of hyperassthesia of the auditory 
nerve follows, certain sounds being painful, although the gen- 
eral auditory power is greatly impaired. An attack of this 
kind renders it probable that subsequent attacks may occur, 
especially when it is due to a pathological condition of the 
walls of the blood vessels. 

Diagnosis. — The suddenness of the attack, the severity of 
the vertigo and of the tinnitus, the extreme nausea, and the 
sudden and marked impairment in hearing form a series of 
symptoms which are fairly characteristic. A physical exami- 
nation reveals no departure from the normal standard. 

Functional examination, in addition to the impairment of 
hearing, both for spoken words and sharp sounds, will show 
an impairment or absence of sound perception through the 
solid media of the skull. The limits of audition may be vari- 
ously affected, according to the particular site of the lesion. 
Generally the lower portion of the labyrinth is involved, in 
which case the lower tone limit remains normal, while the 
upper tone limit is lowered to a very marked degree. This 
is not absolute, for if the haemorrhage occurs in the upper 



6io LABYRINTHINE 

part of the cochlea high notes may be the only ones heard, 
while the low notes are not perceived at all. 

Prognosis. — When the haemorrhage involves but a very 
small area, spontaneous recovery may take place. When the 
lesion is extensive it is probable that the hearing will remain 
to a degree impaired whether the case be left to itself or sub- 
jected to medication. Improvement may be hoped for in the 
more severe cases rather than in those where the extravasa- 
tion is moderate. The prognosis as to the disappearance of 
subjective noises is less favorable, and complete relief should 
never be promised. The disturbance oi the equilibrium usu- 
ally disappears completelv. 

Treatment. — When seen immediately after the attack, local 
iepleti m and even general bloodletting are the first measures 
: be instituted. A wet cup to the mastoid exerts more influ- 
ence up on the circulation within the labyrinth than when ap- 
plied in any other location. Free purgation should then be 
effected, absolute rest in bed enjoined, and the patient should 
be protected, as far as possible, from loud noises, and forbid- 
den to do anv manual work. At a later period the adminis- 
tration of pilocarpine, beginning with a dose of one sixth of 
a grain three times dailv and increasing rapidlv until the 
phvsiological effect is obtained, often causes rapid imprr.r- 
ment by reducing labvrinthine pressure. The general condi- 
tion should be attended to in the same manner as directed 
under labvrinthine hyperaemia. Iodide of potassium, con- 
tinued for six or eight weeks, seems to favor the absorption 
:: the clot. Counter-irritation over the mastoid process by 
means of iodine or vesicants is a measure to be emploved if 
i nvales :-r.ce is delayed. Great care should be taken to warn 
the patient of the danger :: a similar attack at some future 
time. 



CHAPTER XXXVI. 

LABYRINTHINE EMBOLISM AND THROMBOSIS. 

Etiology. — The lodgment in one of the smaller vessels of 
the internal ear of an infectious embolus which may have 
been thrown into the circulation as the result of a patho- 
logical change in some distant organ, or the development of 
infectious thrombi within the venous channels, are both con- 
ditions met with in rare instances. Embolism is specially 
rare, although it has occurred in cases of osteomyelitis, and 
has been produced artificially in the lower animals by the 
injection of some of the low vegetable organisms into the 
blood. A thrombosis occurs more frequently as the result of 
a severe suppurative process within the middle ear, such as 
is found in scarlatina, diphtheria, etc. Here the blood supply 
of the external labyrinthine wall is greatly interfered with, 
and infection takes place by contiguity of structure through 
the osseous partition. This form of occlusion of the venous 
channels constitutes the labyrinthine lesion in many cases 
which suffer from severe purulent otitis during one of the 
exanthemata. 

Pathology. — The occlusion of an arterial twig produces at 
first an anasmia of the area which it supplies ; this may go on 
to disintegration if the blood supply is not re-established, but 
if the collateral circulation is free this may not occur. Throm- 
bosis of a venous trunk is of less importance except where it 
is due to an acute infectious process, when the minute septic 
foci may break down and produce severe inflammation of the 
surrounding parts. 

Symptomatology. — The symptoms, in general, resemble 
those of labyrinthine haemorrhage, except that thev are less 
severe ; nausea is rare ; vertigo may be scarcelv noticeable, 
and the hearing power but slightly impaired. The sudden 
development of tinnitus in these cases is probably the most 
constant symptom. It is probable that in many instances 
where tinnitus alone is complained of, the hearing power 

(611) 



612 LABYRINTHINE EMBOLISM AND THROMBOSIS. 

being normal, according to the most careful tests, a small 
artery or vein within the labyrinth has become occluded, 
causing sufficient structural change to produce this symptom 
without otherwise impairing the function of the organ to a 
noticeable extent. From the intimate relation between the 
venous current within the turbinated bodies and that of the 
cochlea, we might suppose that a suppurative inflammation of 
one of the accessory sinuses, such as the ethmoid, antrum, or 
frontal sinus, would be particularly prone to produce this 
effect. It is certainly true that many of these cases suffer 
from subjective noises, while the history shows that the onset 
was sudden, that the noise has remained unchanged for a con- 
siderable number of years, or has perhaps slightly diminished, 
while any impairment of hearing that existed in the early stage 
of the affection has disappeared. Here the inference, that 
embolism of one of the minute vessels has been the lesion 
which has produced the symptom, seems logical. 

Prognosis. — Extensive destruction of the labyrinthine 
structures frequently follows a severe suppurative inflam- 
mation within the tympanum. When confined to a small 
area the condition usually improves as age advances, and 
although it sometimes disappears spontaneously, it is often 
unaffected by treatment. The lesion does not tend to pro- 
gress, and either remains quiescent or slowly improves. 

Treatment. — The first indication is to remove the cause, 
to prevent a repetition of the accident. Measures directed 
toward the labyrinth itself may be necessary where the affect- 
ed area is extensive. The reduction of labyrinthine pressure 
by the internal administration of pilocarpine and subsequently 
of iodide of potassium is practically the most serviceable plan 
of treating either thrombosis or embolism. For the constant 
tinnitus, the use of dilute hydrobromic acid in full doses will 
be found to be beneficial not only in relieving the symptom, 
but, by reducing the degree of hyperesthesia of the recep- 
tive centres, will often exert a certain curative effect. The 
drug should be given in doses of half a drachm every four 
hours, or more frequently if necessary. It should be well 
diluted with water, to avoid irritation of the stomach. Strych- 
nine in full doses is also of value in preventing a rapid disor- 
ganization of the nerve tissue supplied bv the occluded vessel 
both bv its specific effect upon nerve tissue and its action as 
a cardiac stimulant. 



CHAPTER XXXVII. 

SPECIFIC INFLAMMATION OF THE LABYRINTH. 

JEtiology. — This portion of the receptive mechanism may 
be the seat of changes due to hereditary or acquired specific 
disease. In the hereditary cases the association of intersti- 
tial keratitis is so frequent as to point to the dependence of 
both conditions upon the same cause. When it occurs as the 
result of acquired specific disease, it is usually found in the 
tertiary period, although very rarely it is met with in the 
secondary stage. 

Pathology. — The changes which are found upon post- 
mortem examination are of a chronic inflammatory character. 
The lining membrane of the semicircular canals and cochlea 
is thickened, narrowing the lumen of the channels, and in 
some instances this process has gone on to the development of 
new osseous tissue, causing a thickening of the bony walls of 
the passages. Changes characteristic of specific disease are 
present in the blood vessels ; they consist in an obliterating 
endarteritis, narrowing or completely occluding the vessel 
lumen. From this the parts are supplied with an insufficient 
quantity of blood, and suffer from impaired nutrition, which 
may cause necrosis if sufficiently complete. Where the nutri- 
tion is seriously interfered with the parts may undergo sof- 
tening, in the same manner as occurs in gummata in various 
parts of the body. When there is a hypertrophic process 
within the vestibule the newly formed bone may be depos- 
ited about the oval window, producing a thickening of the 
foot plate of the stapes or a synostosis of the stapedio-vestibu- 
lar articulation. 

Symptomatology. — The occurrence of sudden and pro- 
found impairment of hearing, with the development of sub- 
jective noises, in an adult apparently in perfect health and 
with no evidences of middle-ear involvement, should always 
excite suspicion of an underlying specific cause. In the he- 
reditary cases the impairment in hearing may be steadily 

(613) 



614 SPECIFIC INFLAMMATION OF THE LABYRINTH. 

progressive, and associated with ulceration of the cornea, as 
before mentioned. In children this combination of symptoms 
is particularly liable to occur, and, unless checked by treat- 
ment, progresses rapidly, so that the hearing power becomes 
almost completely lost in a short time. Disturbances of equi- 
librium are not common, and when present are usually slight. 
The association of middle-ear symptoms may be confusing, 
and mask for a time the true cause of the attack. 

Diagnosis. — The diagnosis depends upon the suddenness 
of the onset and the profound degree of impairment in hear- 
ing, while vomiting and severe vertigo are absent. 

If physical examination reveals the middle ear normal, the 
diagnosis is rendered much more simple ; when occurring in 
the secondary stage, an associated tubal or tubo-tympanic in- 
flammation may be so marked as to lead the observer to sup- 
pose that the symptoms are entirely due to the condition of 
the middle ear, and the labyrinthine lesion may be overlooked 
entirely. Functional examination, however, ordinarily pre- 
vents this error. The low notes are fairly well heard even if 
the middle ear is involved, the lower tone limit not being 
elevated proportionately to the degree of impairment of hear- 
ing. The upper tone limit is very much lowered, and sharp 
sounds are poorly perceived, the impairment in this direction 
being more marked than the impairment for conversation. 
Bone conduction is greatly reduced or entirely absent, thus 
rendering the error of attributing symptoms to an affection 
of the middle ear almost impossible. Other signs of specific 
disease should also be sought for. In children, an examination 
of the teeth often reveals characteristic " Hutchinson teeth," 
while the surface of the body may present evidences of a pre- 
vious specific eruption. The examination of the skin is of 
particular importance in adults where the disease is acquired 
rather than hereditary. The association of ulceration of the 
cornea should also be regarded with suspicion. 

Prognosis. — The difficulty in determining the value of any 
form of medication in these cases depends upon the fact that 
the disease may remain quiescent for a long period, and sud- 
denly be excited to renewed activity by some intercurrent 
disease, or from no assignable cause. 

We therefore can not always say whether the cessation of 
the symptoms occurs spontaneously or is the result of treat- 
ment. Medication is of value in recent cases without ques- 



TREATMENT. 615 

tion, but in those of hereditary origin many believe that the 
disease can not be checked by therapeutic measures. In spite 
of this, no case should be considered as hopeless without hav- 
ing been first subjected to a thorough course of specific 
treatment. 

Treatment. — In no class of labyrinthine cases is treatment 
more gratifying than in those depending upon acquired spe- 
cific disease. Cases due to a hereditary taint respond less 
promptly to treatment, and many go so far as to assert that 
improvement never follows the exhibition of drugs. In this 
latter class of cases my experience is so limited that I do not 
feel warranted in giving a personal opinion on the subject. 
In the acquired cases, however, even after a considerable 
time has elapsed since the aural symptoms were first noticed, 
internal medication has been followed by gratifying results. 
The internal administration of pilocarpine, beginning with 
doses of one sixth of a grain and increasing the dose until the 
physiological effect of the drug is obtained, as fully described 
in a previous chapter, is almost invariably followed by im- 
provement, both as regards the subjective noises and the 
hearing. Its action is much more marked if, in connection 
with it, we exhibit the iodide of potassium in full doses, begin- 
ning with ten grains three times daily, and increasing it to 
two or four drachms daily. In addition — or at intervals, 
during which the iodide is discontinued — small doses of the 
bichloride of mercury (one thirty-second to one sixteenth of 
a grain three times daily) have been found of value. If, coin- 
cident with the labyrinthine affection, the tympanum is also 
involved, this should be treated as a simple middle-ear inflam- 
mation, according to the rules already laid down, the local 
measures employed in no way interfering with the lesion 
within the labyrinth. The use of mercurial ointment about 
the ear is probably of but little value, better results being 
obtained by giving a mercurial by the mouth. In recent 
cases, where it is desirable to obtain the constitutional effect 
of mercury as soon as possible, the process of general inunc- 
tion, or of baths of mercurial vapor, may be used, as in the 
treatment of any manifestation of a recent specific infection. 
Locally, however, the use of mercurial ointment is of no 
value. In the hereditary cases the treatment should be di- 
rected to an improvement of the general health, as well as 
toward the specific taint. In addition to the iodide of potas- 



616 SPECIFIC INFLAMMATION OF THE LABYRINTH. 

sium, cod-liver oil, hypophosphites, iron, etc., should be given, 
and the diet of the patient should be as liberal as possible. 
The surroundings of the patient should receive attention, and 
every effort should be made to keep him in a condition which 
will render him less susceptible to the action of the heredi- 
tary taint. 

Strychnine is of value in some cases, but must be given in 
full doses. For an adult not less than a fifteenth of a grain 
should be given three times daily. The initial dose must, of 
course, be small, but the quantity should be rapidly increased. 
The appearance of unpleasant symptoms will be an -indication 
for reducing the dose. As already stated, the results will be 
to an extent uncertain. 



CHAPTER XXXVIII. 

INFLAMMATION OF THE LABYRINTH SECONDARY TO CHRONIC 
SUPPURATIVE AND NONSUPPURATIVE INFLAMMATION OF 
THE TYMPANUM. 

Pathology. — Where the tympanic structures have been 
subjected for a long time to an abnormal degree of pressure 
from an adhesive process within the tympanum, certain 
changes take place within the bony capsule, both as the 
direct result of mechanical pressure and also from the ab- 
lation of function which this increased pressure causes. 
Owing to the augmentation in the tension within the laby- 
rinth, the delicate terminal filaments of the auditory nerve in 
the lower part of the cochlea and in the vestibule may be 
completely destroyed. On the other hand, the increased 
tension may prevent the conduction of aerial vibrations to 
these nerve-end organs, and, on account of the disease in the 
middle ear, they may undergo atrophy from disuse, so that 
if the pressure is removed and the normal tension within the 
labyrinth is restored, they will be no longer able to perform 
their function. The inflammatory process within the tym- 
panic cavity may be propagated to the adjacent labyrinthine 
parts by contiguity of structure. This is especially true in 
those cases of otitis media arising from the deposit of new 
connective tissue in the niche of the oval or round window. 
By extension, the parts beyond the foot plate of the stapes 
undergo similar changes ; the vestibular walls become thick- 
ened, the process at first resulting in thickening of the peri- 
osteum, and subsequently in the deposit of new osseous 
tissue, thus encroaching upon the lumen of the vestibule. 
Similar changes about the round window result in an en- 
croachment upon the lumen of the first turn of the cochlea. 
This process is quite characteristic of proliferous otitis media. 
It is also, as Politzer has recently shown, quite commonly 
found in advanced life, and constitutes the prominent lesion 
in the presbycusis. 

41 (017) 



6x8 INFLAMMATION OF THE LABYRINTH. 

The changes which take place within the labyrinth in 
chronic purulent otitis media are usually less marked than in 
the nonsuppurative form of the affection. Those met with in 
residuary cases, where the purulent inflammation has run its 
course, are due to pressure or disuse, or to both combined. 
While there is active suppuration, an actual infection of the 
labyrinthine structures may take place through the fenestra 
ovalis or the fenestra rotunda, leading to a purulent inflamma- 
tion of the labvrinth. This may be transmitted, either through 
the blood vessels or through the aquaeductus vestibuli or 
aquaeductus cochleae, to the meninges, and cause a leptomenin- 
gitis. In the labvrinth such a purulent inflammation results 
in a disintegration of the structures involved. This would 
mean complete destruction of the labyrinth if the entire re- 
gion were affected. Fortunatelv, however, such an inflamma- 
tion is frequently confined to the immediate neighborhood of 
the external labyrinthine wall, and its destructive effects are 
limited to the vestibular structures and to those elements 
lying in the first turn of the cochlea. Meningitis seldom 
occurs by infection through the lymph channels of the inter- 
nal ear, and this of itself argues strongly against anv free 
anastomosis between the vessels of the middle ear and those 
of the labyrinth immediately adjoining. Suppuration within 
the tympanic cavity may produce changes due to pressure 
alone, infection not taking place. In such an event the parts 
may be restored to their normal condition by treatment of the 
tympanic affection, and will then resume their proper function. 

In addition to these structural changes, recognizable under 
the microscope in pathological specimens, we must remember 
that in many cases, probably, in which the middle ear is the 
seat of a chronic inflammatory process, the labyrinthine struc- 
tures in the immediate vicinity of the tympanum become 
congested, and remain in this condition for a considerable 
period, without actual tissue metamorphosis. The vascular 
disturbances consist either of increase in the arterial sup- 
ply, or a diminution of the venous outflow, augmenting the 
labyrinthine tension and giving rise to symptoms, although 
microscopic specimens would reveal no structural changes. 
We are warranted, however, in the supposition that these 
conditions are present from the history of certain cases. 

Symptomatology. — The exact line of demarcation between 
symptoms dependent upon middle-ear or labyrinthine changes 



SYMPTOMATOLOGY— TINNITUS. 619 

can not be drawn. All symptoms of impairment or perver- 
sion of function must, strictly speaking, be relegated to the 
perceptive tract, and it is difficult to say when they are pro- 
duced by mechanical irritation simply, from alterations in the 
tension of the conducting apparatus, and when certain changes 
have actually taken place in the labyrinth itself. The most 
constant symptom is undoubtedly the presence of subjective 
noises. In the early stages of a nonsuppurative otitis media 
the persistence of tinnitus should be looked upon as an indi- 
cation that the labyrinth is at least congested, and, unless 
prompt measures are taken for the relief of the condition, 
must soon become the seat of organic changes. The sub- 
jective noises vary in character and in intensity. At first they 
are intermittent, occurring chiefly when the recumbent posi- 
tion is assumed, as this posture favors a determination of 
blood to the head. In neurotic individuals any severe nerv- 
ous strain, or even physical exertion, will serve to increase 
them. The same is true of impairment of the general health, 
or asthenia following a severe illness. 

When these noises are intermittent, and due chiefly to 
congestion, they are frequently synchronous with cardiac 
pulsations ; but as the disease advances this pulsating tin- 
nitus diminishes, and is replaced by a constant high-pitched 
musical sound as the lower portion of the receptive tract 
becomes involved. These patients also complain that, in ad- 
dition to this high-pitched musical note, they hear at irregu- 
lar intervals loud, low-pitched sounds, variously described 
as rumbling, roaring, thumping, or booming noises. We 
may surmise that these are produced by changes within the 
cristae and acusticas. In those cases where the tympanic 
process is confined chiefly to the region of the oval or 
round windows the interference with sound transmission 
may be so slight as to occasion very little impairment in the 
hearing, and the subjective noises may constitute the sole 
symptom of which the patient complains, the labyrinthine 
structures being involved at a very early period. As the 
process advances, the subjective noises change their charac- 
ter, becoming of lower pitch, and finally they may disappear 
entirely, owing to a complete destruction of the nerve fila- 
ments. This same general train of symptoms is occasionally 
met with in cases of chronic suppurative inflammation where 
the process is still active, or in residuary cases, but is always 



620 INFLAMMATION OF THE LABYRINTH. 

present to a much less degree than in the instances of hyper- 
plastic otitis media. The reason for this is probably twofold, 
the first being that the process within the tympanum has 
been followed by destruction of portions of the conducting 
mechanism, and increased labyrinthine tension may be pres- 
ent to only a very slight degree. As a second reason, we 
should remember that the inflammatory process within the 
labyrinth itself is not of such a character as to lead to the 
deposit of new tissue, but to an increase in the amount of 
perilymph. This increase takes place slowly, and is com- 
pensated for by the passage of the fluid outward into the 
endocranial lymphatic spaces. 

In addition to the tinnitus, disturbance of the equilibrium 
is frequently complained of. This points to the invasion of 
that portion of the labyrinth in immediate relation with the 
semicircular canals, as well as involvement of the canals 
themselves. The vertigo may be constant or intermittent, oc- 
curring only upon some sudden change in the position either 
of the entire body or of the head, or it may be due to visceral 
disturbances. Sudden changes in intratympanic pressure do 
not under normal conditions cause vertigo ; but when the ap- 
paratus which presides over the static condition of the body 
is in unstable equilibrium, even a slight disturbance may cause 
giddiness. A sudden closure of the Eustachian tube — the re- 
sult of an acute rhinitis or naso-pharyngitis — or a powerful 
effort at blowing the nose, or a severe fit of coughing, may 
so alter the pressure as to bring on an attack of dizziness. 
Any process which suddenly increases the blood pressure 
within the labyrinth is capable of bringing on vertigo. Here 
we may mention violent exercise, suddenly lowering the 
head in stooping, intense mental excitement, as either rage or 
grief, etc. 

The vertigo seldom persists, but disappears in late stages 
of the disease. The impairment of hearing varies greatly in 
degree, and the subjective symptoms may cause the patient 
to seek relief before he has noticed any change in the power 
of audition. The reason of this is that the perception of 
the highest notes of the musical scale is of little use in the 
ordinary vocations of life, and conversation may be perceived 
without difficulty, although the upper tone limit is consid- 
erably lowered. 

The clinical history detailed above presupposes the in- 



INVOLVEMENT OF OPPOSITE EAR. 62 1 

volvement of but one ear. Sooner or later the organ of the 
opposite side becomes involved, and then the impairment in 
function becomes decidedly noticeable and increases with 
great rapidity. The balance of evidence at present seems to 
favor the view that the involvement of the ear of the oppo- 
site side is due to an extension of the process from the one 
first attacked, rather than that it is dependent upon an inflam- 
matory process similar in character but of primary origin. 
This extension can readily be understood if we remember 
the crossing of the fibres of the eighth nerve in the medulla, 
through which the cortical auditory region receives fibres 
from the labyrinth of either side, but chiefly from the oppo- 
site labyrinth. An involvement of this principal terminal ap- 
paratus would cause degenerative changes to take place in 
the centre itself. These, in turn, would excite certain dis- 
turbances in that portion of the cortex deriving its supply 
from the nerve of the side corresponding to the cortical area, 
thus ablating the function of this portion of the cochlea of 
this side. Clinical observation shows that in a large propor- 
tion of cases of hyperplastic otitis media, with complicating 
labyrinthine involvement, the labyrinthine changes in the ear 
last affected are more extensive than those in the organ first 
involved. Of twenty-six of my own cases, sixteen exhibited 
this condition.* The tympanum also becomes involved sec- 
ondarily, but to a much less extent than the labyrinth, and 
the impairment of function seems to be due chiefly to the 
labyrinthine changes. These alterations occur so rapidly 
that the patient not infrequently presents with the history 
that the ear first involved is at present of the most use to 
him. It is of great importance to obtain a correct history 
of the case, and we should learn definitely, if possible, in 
which ear the impairment of hearing began, and at what 
period. Unless great care is taken to obtain these data a 
grave error may be made. 

After the terminal filaments of the auditory nerve have 
been the seat of changes for a considerable period, the sub- 
jective noises, which were at first distressing, become less 
severe, owing to the complete ablation of function of this por- 
tion of the cochlea. The spontaneous cessation of tinnitus in 
one ear furnishes a clew to the information desired, and it is 

* New York Eye and Ear Infirmary Reports, 1894, vol. ii, p. 62. 



622 INFLAMMATION OF THE LABYRINTH. 

usually the case that the organ first involved causes less dis- 
tress from this cause than does its fellow. Where the tym- 
panic process is marked in the ear last involved, the symp- 
toms differ in that the impairment of hearing is usually about 
equal upon the two sides, or audition is perhaps slightly bet- 
ter upon the side last involved. 

Diagnosis. — A. Physical Examination. — Upon inspecting the 
ear we have presented a picture of chronic catarrhal inflam- 
mation, or the various changes resulting from a suppurative 
process. In the nonsuppurative variety the parts may vary 
but little from the normal standard, as far as appearances are 
concerned, the reason being that the pathological changes 
take place mostlv at the oval and round windows. The more 
external parts of the conducting mechanism may be but little 
affected. The color, density, lustre, and position of the drum 
membrane may be within normal limits, provided the changes 
have been hyperplastic from the start. In those cases sec- 
ondary to a hypertrophic process the position of the drum 
membrane is usually abnormal : it is commonly retracted to a 
greater or less degree, and presents variations in density in 
different areas, while the breadth of the malleus handle is 
either greater or less than under normal conditions, from a 
rotation of this ossicle upon its long axis. This has been 
fully described in a previous chapter. 

Where the internal ear is involved as the sequel to a sup- 
purative inflammation which has run its course, the appear- 
ances vary according to the amount of destruction which has 
taken place. The postero-superior quadrant is the region to 
be particularly inspected as throwing light upon the probable 
cause of the involvement of the perceptive portion of the 
auditory svstem. We may find the stapes forced deeply into 
the oval niche and fixed by adhesions, which bind the crura 
flrmlv to the borders of the pelvis ovalis. or a tense posterior 
fold may cause a similar condition. The niche of the round 
window is quite frequently in view, and should always be 
examined for adhesions, as these may plav an important part 
in the production of the symptoms. Where the stapes has 
become separated from the incus, during the course of a sup- 
purative inflammation, the condition of the other ossicula may 
be practically disregarded, since the structures within the pel- 
vis ovalis and niche of the round window alone affect the con- 
dition of the labyrinth. In the nonsuppurative cases it is 



FUNCTIONAL EXAMINATION. 623 

important to determine whether the middle-ear affection has 
become quiescent, or whether it is still active and progress- 
ive. To decide this definitely is often impossible ; although 
hyperemia at the inner extremity of the bony meatus, close 
to the tympanic ring, may usually be looked upon as an evi- 
dence that the tympanic affection is still active, while, if the 
parts are pale, the process is probably quiescent, and the laby- 
rinthine changes are not liable to be augmented by the fur- 
ther progress of the middle-ear lesion. 

B. Functiojial Examination. — The hearing is impaired both 
for sharp sounds and for whispered or spoken words. It 
may be roughly stated that where the labyrinthine involve- 
ment is extensive, sharp noises are relatively more poorly 
heard than speech, the converse being true when a tympanic 
affection predominates. 

The lower tone limit is elevated, the upper tone limit re- 
duced, the degree varying with the extent of the labyrinthine 
lesion ; bone conduction is decidedly diminished or may be 
entirely absent. Rinne's experiment will be negative for the 
lower notes of the scale, becoming positive as the test is made 
with the higher forks. It is now important to determine in 
any given case how much of the impairment depends upon 
the condition within the tympanum and how much upon the 
secondary labyrinthine changes. If we compare the degree 
of defective audition for whispered or spoken words with the 
point in the musical scale at which Rinne's experiment be- 
comes positive, we have an estimate of the relative amount 
of middle -ear and labyrinthine involvement. Where this 
point lies high in the musical scale in cases where the func- 
tion is impaired to a marked degree, we are warranted in 
the conclusion that the chief trouble lies within the tympa- 
num. Confirmatory of this we find the upper tone limit but 
slightly lowered, and bone conduction either normal or but 
little impaired. Naturally the age of the patient must be 
taken into account in drawing these deductions. If, on the 
other hand, we have to deal with a patient who hears the 
whisper only when the words are repeated close to the ear, 
and Rinne's experiment becomes positive in the lower portion 
of the scale, the tympanum is not the part most involved. In 
such an instance we should expect to find a marked lowering 
of the upper tone limit, and poor bone conduction. In de- 
ciding this question, it is well to make several examinations. 



624 INFLAMMATION OF THE LABYRINTH. 

since any sudden disturbance within the tympanum causing a 
temporary increase in labyrinthine pressure might mislead us. 
The results obtained from functional examination conducted 
in this manner, taken in connection with the history of the 
case, the age of the patient, etc., will seldom fail to render 
the diagnosis clear. Certain symptoms of which the patient 
complains, such as the cessation of subjective noises, the 
presence or absence of paracusis Willisii, evidences of audi- 
tory fatigue, and marked variations in the hearing power 
dependent upon meteorological changes, are also of value. 
With reference to this last symptom, I feel certain that vari- 
ations following changes in the weather are quite as charac- 
teristic of an affection of the cochlea as of one of the middle 
ear. This point has been sufficiently considered in a previ- 
ous section. 

The reaction of the auditory nerve to electrical stimuli is 
of diagnostic value. If a hyperaesthetic condition is present, 
this denotes activity or progression of the disease, but does 
not locate it definitely, since this hyperesthesia may depend 
upon the excitation of the terminal filaments by a progressive 
tympanic inflammation, or it may be the result of an active 
process within the labyrinth. The inspection of the parts 
will usually enable the surgeon to decide whether the tym- 
panic inflammation is active or quiescent, and in this way to 
determine the cause of the hyperesthesia. 

It should be the rule to investigate both ears with equal 
care, otherwise incipient involvement may be overlooked. 
Galvanic hyperesthesia upon one side may depend upon in- 
flammation of the opposite tympanum. 

Prognosis. — Any implication of the peripheral filaments 
of the auditory nerve, secondary to changes within the mid- 
dle ear, constitutes in every case a grave condition. The ulti- 
mate result must be considered both with reference to the 
further progress of the disease and to correcting the effects 
already produced. In the cases following a destructive in. 
flammation within the tympanum, a steady advance of the 
symptoms is seldom looked for. We occasionally meet with 
instances in which a preceding suppurative otitis media af- 
fecting one side only, produces late in life certain disturbances 
in the organ upon the opposite side. When this occurs the 
prognosis as regards the healthy ear is of chief moment, the 
other organ having been practically useless for a long time. 



PROGNOSIS— TREATMENT. 625 

If unchecked by proper measures a steady advance must be 
expected. In nonsuppurative cases the involvement of one 
ear is followed sooner or later by a corresponding process 
upon the opposite side. In unilateral cases, if we can do 
nothing to improve the condition of the affected organ, the 
early adoption of measures directed to the removal of its effect 
upon the opposite ear may stop the progress completely. In 
bilateral cases we may usually assume that where the tym- 
panic disease predominates upon the side first involved, its 
proper treatment will not only improve the function of both 
organs, but will stop the progress of the disease completely. 
With regard to the progress of the labyrinthine lesion in the 
organ first affected, this, almost without exception, advances, 
unless checked artificially, until the function of the ear is en- 
tirely ablated. The probable result of treatment will depend 
upon the extent to which the process has advanced before the 
case comes under observation. Where we judge that a com- 
paratively small portion of the cochlea is involved, we may 
hope to restore the function to a great degree. If extensive 
changes have taken place, complete retrogression must not 
be hoped for. But a considerable amelioration of the symp- 
toms may occur even in cases of long standing. In general, 
those cases dependent upon suppurative disease are much 
more favorable than those where connective-tissue hyperplasia 
has occurred primarily. 

Treatment. — First of all we must remove any condition 
within the tympanum which might cause labyrinthine 
changes. In other words, treatment directed to the middle 
ear is not contraindicated in instances of mixed disease, ex- 
cept in cases where the labyrinthine condition is the most 
prominent feature and has existed for so long a time as to 
render its relief impossible even if the tympanic lesion could 
be overcome. Adhesions must be absorbed or divided ac- 
cording to their density. In suppurative cases surgical 
measures are practically the only ones at our disposal, and 
the stapes and the membrane about the round window must 
be relieved of any increased tension. Tense bands must be 
divided according to the principles of aseptic surgery, and 
this process continued until the niche of the oval and round 
window is perfectly free. In the nonsuppurative cases sur- 
gical measures may be called into requisition, although here 
with less promise of success than in the preceding instances. 



626 INFLAMMATION OF THE LABYRINTH. 

This subject has been thoroughly dealt with under Middle 
Ear Operations, and need not be repeated. The procedures 
are to be instituted both for the organ first affected and for 
its fellow of the opposite side. Concerning the administra- 
tion of drugs, pilocarpine seems to be the remedy best 
adapted to these cases. It is to be administered preferably 
bv the mouth, beginning with doses of one eighth to one 
sixth of a grain twice or three times daily, the amount to be 
increased according to the toleration of the patient. If bene- 
fit is to be obtained, the constitutional effects of the drug must 
be produced, and its administration continued for a period of 
two months, and in many cases longer. No improvement 
should be expected under two weeks or a month, and it is 
frequently delayed beyond this time. 

Where one ear has been considered useless by the patient 
for many years, a condition of torpidity of the auditory nerve 
and corresponding centres manifests itself. This is best com- 
bated by the administration of strychnine in full doses, begin- 
ning with one fortieth of a grain three times daily, increasing 
to one twentieth or one fifteenth if the drug is well borne. 
This drug may be advantageously administered in connection 
with pilocarpine. 

Where there is a history of either hereditary or acquired 
specific disease the iodides in full doses frequently produce 
remarkable results. Much has been written of late upon 
the treatment of these cases by sonorous vibrations by means 
of the phonograph or some similar instrument. This form of 
treatment is by no means new, the idea being mentioned by 
Toynbee,* who reports a case of great improvement follow- 
ing the use of the conversation tube for a considerable period 
of time. In this instance the human voice was the agent em- 
ployed. Later, tuning forks were used for the same purpose, 
the fork being maintained in vibration before the patient's ear 
for a certain length of time, and effecting both massage of 
the rigid ossicular articulations and stimulation of the audi- 
tory nerve itself. The employment of the phonograph, vibra- 
phone, vibrometer and similar devices for effecting the same 
result, is merely an application of this principle, the apparatus 
used being of little importance. 

There is evidence to show that by following this plan sub- 

* Diseases of the Ear, p. 433. 



TREATMENT— GENERAL. 627 

jective noises are reduced in intensity and the hearing in cer- 
tain cases improved. For a considerable period of time I have 
advised the use of some simple form of conversation tube, the 
patient being read to by an attendant for perhaps ten or fif- 
teen minutes twice daily, in a tone of voice that can be easily 
perceived. Any words which are not clearly heard should 
be repeated distinctly at least ten times. In this way the 
torpidity of the receptive centre is overcome and the patient 
learns to interpret correctly the words which he hears, al- 
though they may not be perfectly heard. The process is 
exactly similar to that of a child learning to talk, or of an 
adult learning a foreign language, the sensorium being 
really educated so as to correctly interpret the perverted 
auditory stimuli. 

The relief of subjective noises seldom forms a prominent 
indication for treatment in cases of advanced labyrinthine 
disease. Where these are distressing, however, a period of 
temporary relief may usually be obtained by the administra- 
tion of large doses of hydrobromic acid, and it is wise in all 
cases to employ this drug when the noises first appear. If 
they are allowed to continue, the higher centres become so 
irritated that the removal of the primary cause of the disease 
may fail to relieve this distressing symptom completely. Con- 
cerning the effect of climate upon the progress of the affec- 
tion but little is actually known, and I have never considered 
the matter of climate of sufficient importance to insist upon a 
change of residence for the aural affection alone. Of much 
more importance is the general condition of the patient. 
Overfatigue, mental strain, irregularities in diet, or the ex- 
cessive use of stimulants must be positively interdicted. The 
employment, except when it is imperative, of any drugs — 
such as quinine or salicylic acid — which are known to cause 
an intense congestion of the labyrinth, must also be forbidden, 
since their ingestion, even in small doses, may excite the pro- 
cess to renewed activity. Diathetic conditions must be con- 
trolled, particularly those of a gouty or rheumatic character. 

Treatment of the upper air passages, in the hope of im- 
proving the aural condition, is useless when these measures 
are undertaken for this purpose alone. It is of great impor- 
tance, however, that deviations from the normal standard in 
these regions, which produce local symptoms — such as fre- 
quent colds, imperfect nasal respiration, etc. — should receive 



628 INFLAMMATION OF THE LABYRINTH. 

proper treatment, as variations in the circulation within the 
labyrinth are thus avoided. 

Where extensive involvement of the labyrinth of both 
sides is present, but little relief can be hoped for by the cor- 
rection of any pathological condition within the tympanum ; 
and in certain instances, especially in old people, surgical in- 
terference is positively contraindicated, as the progress of 
the disease is usually rendered more rapid by these measures. 
In cases of extensive unilateral involvement, such measures 
may be justifiable in the hope of preserving the opposite ear, 
but should not be instituted unless there is positive evidence 
that the diseased organ is affecting the healthy one. 



CHAPTER XXXIX. 

ACUTE INFLAMMATION OF THE LABYRINTH SECONDARY TO 
ACUTE PURULENT OTITIS MEDIA. 

etiology. — This form of inflammation of the labyrinth is 
usually confined to those cases in which the middle-ear affec- 
tion depends upon an acute infectious disease, such as scarlet 
fever, diphtheria, measles, epidemic influenza, cerebro-spinal 
meningitis, or typhus fever. It may follow a severe attack of 
suppurative otitis media, developing from exposure to cold, 
from a traumatic cause, such as the accidental introduction of 
fluid into the tympanum, or rupture of the membrana tym- 
pani. It occurs most frequently in child life, at which period 
the petrous portion of the temporal separating the labyrinth 
from the middle ear is thinner and of less density than later 
in life. In order that the entire auditory mechanism should 
be involved in an inflammatory process, the infection must be 
of great virulence, and this depends upon the severity of the 
acute infectious disease. 

Pathology. — This condition has been called, not inappro- 
priately, panotitis. As the result of infection within the mid- 
dle ear the softer structures rapidly break down, while the 
firmer osseous tissue becomes carious, and are either com- 
pletely destroyed or suffer a considerable loss of substance. 
The periosteum covering the inner tympanic wall takes part 
in these changes, and not infrequently an acute inflammation 
of the underlying osseous tissue results. The propagation 
of the condition to the labyrinth may take place either di- 
rectly through the diseased bony wall or at the labyrinthine 
windows. Post-mortem examination frequently shows a de- 
struction of the membrane of the round window, or a loss of 
substance at the stapedio-vestibular articulation, the infectious 
material having entered through these channels. The tissue 
changes which take place do not differ from those observed 
in the middle ear. Microscopic investigation reveals the 
presence of the bacilli of suppuration both in the blood vcs- 

(629) 



630 



ACUTE INFLAMMATION OF THE LABYRINTH. 



sels and in the tissues. Local necrosis occurs early, and the 
firm osseous tissues either disintegrate and are thrown off in 
the profuse secretion incident upon the inflammatory process, 
or the necrosis may result in the formation of a sequestrum, 
which is either discharged spontaneously or is removed by 
surgical interference. The condition may extend from the 
labyrinth to the meninges, either along the sheath of the 
auditory nerve or through the vestibular or cochlear aque- 
ducts, causing a purulent meningitis. These extensive changes 
may cause partial or complete destruction of the end organ 
of the auditory nerve. During the reparative process new 
osseous tissue may be deposited and obliterate the labyrin- 
thine cavity to a greater or less extent. 

Symptomatology. — Occurring in young subjects most fre- 
quently, the symptoms depend upon the intense systemic in- 
fection rather than upon the involvement of the terminal 
portion of the auditory apparatus. The involvement of the 
labyrinth in consequence of an acute process within the mid- 
dle ear announces itself in older subjects by the sudden ap- 
pearance of giddiness, intense tinnitus, and great impairment 
of hearing, the function of the ear being completely abolished 
in many cases. When the inner wall becomes involved in this 
manner, facial paralysis is not uncommon, owing to a partial 
destruction of the aquasductus Fallopii, exposing the facial 
nerve to infection. Occasionally dehiscences are found in 
the osseous covering of the facial nerve when there has been 
no pathological process, in which case a simple inflammation 
of the middle ear produces this symptom without causing 
a loss of substance in the wall of the aquasductus Fallopii. 
Hence, facial paralysis alone is not necessarily an evidence 
that the disease has involved the bony walls. The interfer- 
ence with equilibrium may depend upon the entrance of the 
infectious material into the vestibule, or the horizontal semi- 
circular canal situated high up on the inner tympanic wall 
may be the seat of involvement ; in the latter case disturb- 
ance of equilibrium alone is present, while the function of 
audition is scarcely perverted or interfered with.' The most 
usual avenue of extension is through the oval and round 
windows, with involvement of the vestibule. An inflam- 
matory process in this location produces the characteristic 
symptoms first mentioned, namely, vertigo, tinnitus, and 
impairment of hearing. As the case progresses the vertigo 



SYMPTOMATOLOGY— DIAGNOSIS. 63 I 

is the first symptom to disappear ; next the tinnitus becomes 
less severe, but the impairment of hearing is permanent. 
The membranous portions of the cochlea may be completely 
disintegrated, and the bony passages are sometimes obliter- 
ated by the deposit of new osseous tissue. In many instances 
a large part of the petrous portion of the temporal bone is 
thrown off as a sequestrum. Since the petrous bone lodges 
the internal carotid artery and the internal jugular vein, 
severe haemorrhage from the ear is not an infrequent symp- 
tom of this extensive destruction. If either the carotid or 
jugular is eroded, this haemorrhage is usually fatal. From 
the proximity of the cranial contents, direct infection of the 
meninges may follow, with the characteristic symptoms of 
meningitis. It is probable that a localized inflammation of 
the labyrinthine structures in the immediate neighborhood of 
the fenestra rotunda sometimes occurs, without spreading to 
the entire labyrinth. In those cases which do not terminate 
fatally, the hearing for the upper portion of the musical scale 
remains greatly impaired, and there is but little promise of a 
favorable termination under any plan of treatment. A por- 
tion of specialized end organ of the auditory nerve has been 
completely destroyed by the disease, and manifestly can not 
be regenerated by therapeutic measures. Any portion of the 
cochlea which has remained intact may still respond to the 
stimuli of sonorous vibrations, and the removal of certain 
conditions which interfere with its proper action may pre- 
serve the remnant of the auditory function. 

Diagnosis. — A. Physical Examination. — Speculum examina- 
tion reveals but little in these cases. The picture is one of a 
suppurative otitis media of great severity, and in the early 
stages this is all that can be made out. At a later period the 
presence of carious bone gives rise to the formation of exuber- 
ant granulations in the tympanic cavity, while careful exami- 
nation with the probe may reveal denuded areas upon the 
inner tympanic wall. The profuse discharge is also indica- 
tive of extensive tissue necrosis, and where carious bone is 
present the discharge frequently possesses a strong, disagree- 
able odor. The presence of this offensive discharge is not an 
invariable evidence of dead bone, but should lead to a strong 
suspicion of its presence. 

B. Functional Examination. — In young subjects an exami- 
nation of this kind is manifestly impossible. Occurring in 



632 ACUTE INFLAMMATION OF THE LABYRINTH. 

patients of sufficient age to answer questions intelligently, it 
is often of great service in enabling us to determine the pres- 
ence or absence of the condition in question. Bone conduc- 
tion is either completely abolished or greatly reduced. The 
upper tone limit is lowered to such a degree that the ear may 
respond to no vibrations beyond two thousand per second. 
This fact is explainable on anatomical grounds. Low tones, 
on the contrary, are fairly well heard, although the extensive 
destruction which has taken place within the tympanum ren- 
ders the ear less susceptible to these than under normal con- 
ditions, or in cases of primary labyrinthine disease in. which 
the conducting mechanism is not affected. If we add to this 
complete loss of perception of high musical notes the loss of 
bone conduction and the intense vertigo, we have a combina- 
tion of symptoms which can mean nothing but labyrinthine 
involvement. 

Prognosis. — The prognosis is absolutely unfavorable as to 
the complete restoration of the function of the organ, the 
hearing being completely destroyed in a large majority of 
cases. As to life, the outlook is equally grave, especially in 
young subjects. In adults, extension to the meninges is less 
common, and a favorable termination may be hoped for. 
Much depends upon the degree of infection, and this varies 
with the disease which has caused the inflammation within 
the tympanum. The poisoning is usually so profound as to 
give little hope for the recovery of the hearing, even if the 
aural complication does not prove fatal. Complete ablation 
of audition is less liable to take place in adults than in chil- 
dren, but profound interference with function must always be 
looked for. At an early age this termination means deaf- 
mutism, and it is our duty to bear this in mind in giving an 
opinion. 

Treatment. — After the labyrinth has once become in- 
volved nothing can be done to stay the progress of the in- 
flammation. Our duty lies chiefly in the adoption of prophy- 
lactic measures, in all cases of severe suppurative otitis, for 
the prevention of such an infection. These are embraced 
under the head of thoroughly cleansing the ear by frequent 
syringing, keeping the tympanic cavity as nearly as possible 
in an aseptic condition. Too much stress can not be laid upon 
this point, since the practitioner is usually so much occupied 
with the general disease that he can give but little attention 



TREATMENT. 



633 



to the ears. After the labyrinth has become involved the parts 
should still be kept thoroughly cleansed by syringing, but be- 
yond this nothing can be done. Where tinnitus is the promi- 
nent symptom, large doses of hydrobromic acid or of sodium 
bromide give the most relief. Extension to the meninges may 
be combated by the application of the ice cap to the head, free 
purgation, and absolute rest. During the acute stages noth- 
ing can be done to confine the involvement of the labyrinth 
to a particular area. After the acute symptoms have passed 
away it is advisable to administer the muriate of pilocarpine, 
either hypodermically or by the mouth. The result is uncer- 
tain, but in several cases the author has seen excellent results. 
Strychnine should also be given in full doses after the acute 
symptoms have passed. 



42 



CHAPTER XL. 

INVOLVEMENT OF THE PERCEPTIVE MECHANISM IN THE 
ACUTE INFECTIOUS DISEASES. 

During the course of scarlatina, diphtheria, measles,, 
mumps, typhus or typhoid fever, variola, influenza, etc., the 
organ of hearing is not infrequently the seat of marked 
pathological changes. In scarlet fever, diphtheria, measles, 
and influenza, and to a less degree in variola, the middle ear 
is the part first attacked in most cases, and any labyrinthine 
involvement is due to an extension of the tympanic inflam- 
mation. We meet with instances, however, in which the 
specific poison exerts a direct influence upon the labyrinth, 
in some cases the middle ear remaining healthy, while in 
others there has evidently been a double infection, the laby- 
rinthine process in no way depending upon the changes which 
have taken place in the tympanum. 

Pathology. — In the diseases already enumerated the poison 
is conveyed to the labyrinth through the blood current, and 
excites an inflammation of the tissues which line its bony chan- 
nels, in some cases causing a disintegration of a large portion 
of the terminal apparatus of the auditory nerve, while in 
others the local process does not reach this degree, but results 
in an effusion of fluid into the labyrinthine cavity, with the 
result of increasing the tension upon the contained parts, as 
well as of the membranes covering the round and oval win- 
dows. If the effusion is sufficient in amount to overcome the 
elasticity of these limiting membranes, the function of the 
labyrinth is for a time perverted, particularly for those parts 
lying immediately in the neighborhood of the round and oval 
windows. It is probable that the small capillary channels of 
the aqueducts which permit any excess of perilymph to pass 
into the intracranial lymph spaces are partially occluded, and 
hence relief to pressure in this direction is impossible. Under 
these conditions the disturbance of function depends entirely 

(634) 



SYMPTOMATOLOGY— DIAGNOSIS. 635 

upon the invasion of the labyrinthine cavity, even although 
the middle ear may have been the seat of changes as well. 

Symptomatology. — These cases are characterized by vary- 
ing degrees of impairment of hearing and rather moderate 
subjective noises. In the milder cases in adult life the pa- 
tients hear more poorly in a noise than in a quiet place. The 
impairment of hearing is particularly marked in general con- 
versation. In other instances, and when the primary disease 
which has produced the condition has been severe, a high 
degree of deafness is present, the voice being heard only 
when the patient is spoken to loudly in the immediate vicinity 
of the ear. The exanthemata are particularly prone to affect 
the organ of hearing in this way, and are most common in 
childhood ; at this age such a condition must lead to mutism 
unless speedily remedied, and the recognition of the nature 
of the process is of greater importance in childhood on this 
account. 

Diagnosis. — The diagnosis in these cases depends upon 
the fact that the middle ear is either perfectly healthy, or 
presents changes which are evidently incapable of producing 
the degree of functional impairment present. The functional 
examination is characteristic of labyrinthine changes rather 
than of those met with in a lesion of the conducting appara- 
tus. The lower tone limit may be normal or but slightly 
elevated, even although extensive changes have occurred 
within the tympanum. The upper tone limit is greatly low- 
ered ; bone conduction reduced in spite of the presence of a 
tympanic lesion, or nearly absent where the tympanum is in 
a healthy condition. Not infrequently tone gaps are present 
in the upper portion of the musical scale. 

Prognosis. — When changes are of recent origin, we are 
warranted in believing that considerable improvement may 
follow proper therapeutic measures, and in cases of long 
standing it is by no means impossible to improve the condi- 
tion very materially. In childhood, particularly, internal 
medication is followed by the happiest results, and the pa- 
tients should always have the benefit of the doubt, even al- 
though the case may seem apparently hopeless. 

Treatment. — For the reduction of labyrinthine pressure 
and the absorption of the exudation, the administration of 
pilocarpine first in small doses — the amount being rapidly 
increased as the patient becomes accustomed to its use — 



6 3 6 



THE EFFECT OF ACUTE INFECTIOUS DISEASES. 



causes a marked improvement in the hearing, and the im- 
provement is usually permanent. In cases of long- standing 
the torpidity of the nerve is to be combated by the use of 
strychnine as well. This drug must be administered in much 
larger doses than those ordinarily recommended in order 
that this effect may be produced. An additional indication 
for its administration is to combat the depression which the 
prolonged use of the pilocarpine frequently causes. It is 
scarcely necessary to say that the most careful attention 
must be paid to the general condition of the patient, and in 
the case of children every effort is to be employed to educate 
the power of audition as it improves. 

Having considered involvement of the perceptive appara- 
tus in acute infectious diseases from a general point of view, 
a few remarks may not be out of place in regard to some of 
the particular changes following certain of these maladies. 

Mumps. 

Epidemic parotiditis is particularly prone to affect the 
labyrinthine structures rather than the middle ear. Recent 
investigations seem to prove clearly that this local inflamma- 
tion is due to infection from the blood current in precisely 
the same manner as in a complicating orchitis. The effect 
upon the perceptive apparatus is usually very profound, and 
its occurrence in early life is a not infrequent cause of deaf- 
mutism. 

The symptoms detailed above are all characteristic of 
labyrinthine disease dependent upon this cause. The same is 
true of the diagnostic measures employed and the therapeu- 
tic means at our disposal. 

Regarding the prognosis in these instances, treatment is 
followed by the happiest results if instituted early. When 
the patient does not come under treatment until a considera- 
ble time has elapsed, the complete restoration of function can 
not be hoped for, although moderate improvement may be 
expected. 

Typhus and Typhoid Fever. 

In typhus or typhoid fever interference with sound per- 
ception is probably due to the changes which the specific 
poison of the disease causes in the cerebrum itself rather than 
to any effect upon the terminal filaments of the nerve. That 



INFLUENZA— DIPHTHERIA— EPIDEMIC MENINGITIS. 



6$7 



this is the case seems to be borne out when we consider the 
degree of impairment of hearing- which these patients fre- 
quently present, and its disappearance during the period of 
convalescence. 

Epidemic Influenza ; Diphtheria. 

In epidemic influenza, and in some cases of diphtheria, it is 
probable that the perceptive apparatus occasionally suffers 
through changes in the auditory nerve trunk similar to those 
occasionally found in the optic nerve following these diseases. 
These are of the nature of a peripheral neuritis, and involve 
the nerve trunk to a varying degree. As a result, sclerotic 
changes occur with atrophy of the nerve fibres. 

The interference with function will depend upon the ex- 
tent of the lesion, and the possibility of restoring the parts to 
a normal condition will depend upon the same fact. The 
condition is characterized by an interference with the percep- 
tion of the middle notes of the musical scale, the tone limits 
remaining normal. Bone conduction is not destroyed com- 
pletely, although it is much diminished. The galvanic irrita- 
bility of the nerve is usually increased. 

The treatment should be directed toward the improve- 
ment of the general condition of the patient. Mental and 
physical rest should be secured. The food should be of the 
most nourishing quality, while the general neurasthenic con- 
dition should be combated by the administration of strych- 
nine. After the acute symptoms have subsided, this drug 
should be given in large doses, to secure its well-known spe- 
cific effect upon the nerve tissues. 

Epidemic Cerebro-spinal Meningitis. 

Pathology. — In scarlet fever, diphtheria, measles, mumps, 
typhus and typhoid fever, variola, epidemic influenza, etc., the 
primary invasion of the labyrinth occurs by direct infection 
through the blood current. When the meninges are invaded 
by the specific germ of the disease under consideration, the 
inflammatory process extends along the lymph channels of the 
vestibular and cochlear aqueducts, and involves the structures 
located within the bony labyrinth. During the early stages 
both the perilymph and endolymph are increased in quantity, 
while at the same time their composition undergoes a change 



638 THE EFFECT OF ACUTE INFECTIOUS DISEASES. 

through the action of the specific germ. Later, the bony 
walls are the seat of inflammatory changes. Both the ar- 
teries and veins become dilated. There is a migration of 
white blood cells into the surrounding tissues, and true tissue 
hypertrophy takes place. From the extensive proliferation 
of the blood vessels themselves in the newly deposited tissue, 
the walls of these channels are of unusual tenuity and rupture 
easily. Hence extravasation of blood constitutes one of the 
conditions found. The newly deposited tissue increases in 
density, and may be transformed into bone, in which case the 
semicircular canals or cochlea are partially or completely 
obliterated. In other portions the chief force of the disease 
expends itself in tissue necrosis ; the labyrinthine channels 
being filled with pus. Occasionally the tympanum is invaded 
secondarily by a rupture of the membrane at the round or 
oval windows, allowing the inflammatory products to escape 
into the middle ear. From the tympanic involvement the 
drum membrane is soon destroyed, and a purulent otorrhcea 
manifests itself. Naturally this condition is somewhat rare, 
as death usually takes place before sufficient time has elapsed 
for its completion. 

Symptomatology. — In addition to the symptoms charac- 
teristic of meningeal inflammation, we have vertigo, sudden 
loss of hearing, and intense tinnitus. In very young chil- 
dren the vertigo may be the only evident symptom, on ac- 
count of the age of the patient. Occurring in older indi- 
viduals, the access of subjective noises is usually sudden, 
while their intensity is so great as to be agonizing. The 
hearing is either completely destroyed at once, or this con- 
dition occurs at the end of a few hours after the appearance 
of the symptoms. Preceding these marked evidences of laby- 
rinthine invasion, the power of audition may be abnormally 
acute, probably from the hypersemic condition of the laby- 
rinthine structures. This hyperacusis may be so marked that 
faint sounds even are painful, the patient starting at the slight- 
est noise, and complaining of an increase in the headache 
characteristic of meningitis. After a short time the subjective 
noises diminish, owing to the destruction of the terminal fila- 
ments of the eighth nerve, and the hearing remains pro- 
foundly impaired for the same reason. The power of equi- 
librium gradually returns, although this is more slow, per- 
haps, than the disappearance of the subjective noises. The 






DIAGNOSIS— PROGNOSIS. 



639 



involvement of the middle ear is evidenced by the ordinary 
symptoms of an acute purulent inflammation arising from 
any other cause. 

Diagnosis. — A. Physical examination is of importance in 
that it yields absolutely negative results, the membrana tym- 
pani and meatus presenting a normal appearance. From the 
absence of any deviation from the standard of health, togeth- 
er with the presence of subjective symptoms referable to the 
ears, suspicion is naturally directed toward the nervous ap- 
paratus. 

Functional Examination. — B. Impairment of hearing, both 
for sharp sounds and speech, is either profound or the patient 
is absolutely deaf. If any power of audition remains, it is 
usually for the low notes of the scale, the higher notes not 
being heard at all. Rare exceptions are found where the 
apex of the cochlea is first involved. This, however, occurs 
but seldom ; in fact, the lower notes of the scale may be heard 
with abnormal clearness during the stage of hypersemia on 
account of the hyperassthetic condition of the nerve. Bone 
conduction is greatly diminished, and after a few hours is 
absolutely lost. It may be completely absent, although the 
ear may still perceive sounds by aerial conduction. 

Prognosis. — If the patient recovers from the meningeal 
inflammation the outlook for the preservation of hearing is 
exceedingly grave. In severe cases absolute deafness results, 
while in the milder instances a certain amount of audition 
may be preserved. The disappearance of the subjective 
noises is a rather unfavorable symptom, since it denotes com- 
plete anaesthesia of the auditory nerve or perceptive centres, 
and often absolute destruction of the terminal nerve filaments. 
The involvement of the labyrinth in no way affects the prog- 
nosis as regards life. This disease is of particular moment 
when met with in very early life, since the loss of the audi- 
tory perception renders the patient mute as well as deaf. 
This is true even if the child has learned to talk fairly well, 
such words as have been learned being forgotten. In older 
children mutism may not follow, since the association between 
written and spoken words is sufficient to preserve the power 
of speech. The effect of treatment is usually unsatisfactory 
in the severe cases, although in the less severe cases, where a 
certain amount of hearing has been preserved, the function of 
the organ may be still further improved. 



640 THE EFFECT OF ACUTE INFECTIOUS DISEASES. 

Treatment. — But little can be done to prevent the exten- 
sion of the meningeal inflammation to the labyrinth. With 
the development of the hyperacusis it is wise to apply cold 
locally to the mastoid process, while at the same time free 
bloodletting is advisable, provided the general condition of 
the patient will admit of this. Free catharsis should also be 
obtained if the general condition does not contraindicate it. 
If our efforts are unsuccessful, nothing can be done until the 
acute symptoms have subsided, after which the reduction of 
labyrinthine pressure by the use of pilocarpine, either ad- 
ministered hypodermically or by the mouth, is always advis- 
able, and is frequently followed by favorable results. This 
is true, although the patient may not present for treatment 
until a considerable period after the attack of meningitis, and 
where a careful examination seems to indicate that even a 
small portion of the cochlea has escaped destruction, the util- 
ity of the organ can usually be improved. In addition to the 
pilocarpine, strychnine in large doses is an agent of consider- 
able value in preventing a rapid degeneration of the nerve 
fibres in the trunk, from the changes which have taken place 
in the labyrinth. When the acute symptoms have completely 
subsided, exercise of the organ, either through the agency of 
the human voice — a conversation tube being used, if necessary 
— or by the employment of some instrument based upon the 
principle of the phonograph, may still further improve the 
hearing. It is to be specially remembered that both dynamic 
and therapeutic measures must be continued for a long period 
in order to be of the least value, and any slight gain is to be 
looked upon as encouraging. It is wise, in case pilocarpine 
is to be administered for a long period, to occasionally stop 
it altogether for an interval of one to three weeks, after which 
it is to be resumed, beginning with small doses. The general 
condition of the patient must always be kept as near normal 
as possible, and all conditions are to be avoided which disturb 
the labyrinthine circulation either directly or indirectly. 



CHAPTER XLI. 

INVOLVEMENT OF THE PERCEPTIVE MECHANISM IN ACUTE 

MENINGITIS. 

Pathology. — Meningitis of the nonepidemic type may pro- 
duce secondary changes in the labyrinth in the same manner 
as the epidemic form of the disease. A traumatic meningitis 
is usually localized, and consequently the labyrinthine in- 
volvement is unilateral as a rule. In addition to direct exten- 
sion through the labyrinthine aqueducts, the function of audi- 
tion may be interfered with either by direct pressure of the 
products of inflammation upon the auditory nerve trunk, or 
by the involvement of the nerve sheath itself in the process, 
or by a localized meningitis over the cortical auditory area. 
When the labyrinth is the seat of the lesion, the process differs 
from that met with in the epidemic variety of the disease, in 
that it is less extensive and seldom leads to the complete de- 
struction of the parts within the bony capsule. Pressure 
upon the nerve trunk causes degeneration of the nerve fibres 
according to well-known physiological laws, but seldom 
causes a destruction of all the fibres of the trunk. A cortical 
lesion presents essentially the same characteristics in that the 
entire sensory area is seldom destroyed. 

An idiopathic meningitis interferes with the auditory 
function in the same manner, the exact pathological process 
depending upon the location of the intracranial lesion. 

Symptomatology. — The symptoms will vary according to 
the particular location of the meningeal inflammation. Where 
direct extension to the labyrinth occurs, subjective noises of 
varying intensity, moderate or severe vertigo, and a varying 
degree of impairment of hearing are present. The severity 
of each of these symptoms will depend upon the extent to 
which the labyrinth is invaded. Where the trunk of the 
nerve is attacked the same conditions are present, although 
here the auditory impairment is the prominent symptom, and 
is usually most pronounced for the middle notes of the scale. 

(6 4 i) 



642 THE PERCEPTIVE MECHANISM IN ACUTE MENINGITIS. 

perception for high and low notes being fairly well preserved. 
In either case the impairment of function is unilateral, the 
opposite organ remaining perfectly healthy. 

Meningitis over the convexity of the brain involving the 
cortical perceptive area interferes with the function of both 
ears, the defect being most marked upon the side opposite to 
the cortical area involved. 

If the affection is labyrinthine there is but little tendency 
to an increase in the symptoms, but rather to a spontaneous 
retrogression. Where the nerve trunk or the cortical cen- 
tres are the parts primarily involved, the symptoms increase 
or diminish according as the meningitis becomes more dif- 
fuse or yields to appropriate therapeutic agents. In trau- 
matic cases the area affected may be so located as to cause 
an interference with equilibrium alone, the hearing remain- 
ing intact, while tinnitus is absent. Another symptom quite 
characteristic is the development of hyperacusis or dysacusis, 
this latter symptom corresponding to the familiar ocular 
disturbance, photophobia, so characteristic of meningeal in- 
flammation. 

Lesions involving the cortical areas, or the paths of com- 
munication within the brain itself, produce the quite char- 
acteristic symptom of word deafness; the sound is heard but 
is not interpreted, or, if interpreted, is recognized imperfectly 
or slowly. A somewhat similar condition presents when the 
trunk of the nerve is involved, on account of the interference 
with the middle portion of the musical scale. As this por- 
tion of the register is the one ordinarily employed in conver- 
sational speech, the power of interpreting language is some- 
what perverted, especially when the conversation is general. 
Complete deafness for any particular word or combination 
of sounds does not exist, however, but simply impairment. 
Again, as we shall see, the complete functional examination 
of the case enables us to distinguish with considerable ex- 
actness between the two conditions. While a labyrinthine 
lesion in the early stages is characterized by distressing tin- 
nitus, any inflammation of the meninges which causes either 
pressure upon the nerve or upon the cortical perceptive area 
does not, as a rule, present this characteristic. Where pres- 
sure is exerted upon the trunk of the nerve, atrophy takes 
place quite early ; hence any noise which may have been 
present in the incipient stage may disappear ; and the same 



DIAGNOSIS— FUNCTIONAL EXAMINATION. 



643 



is true where the lesion is cortical. The future progress of 
the case will depend upon the intracranial changes present. 
In traumatic meningitis the disappearance of the acute local 
lesion will either be followed by a rapid decrease in the 
symptoms if the products of the inflammation are absorbed, 
or the condition may remain permanent, there being no tend- 
ency to progression. This is true of those cases where 
either an epidural or cerebral abscess does not follow. If 
either of these conditions is present the symptoms increase 
as the localized collection of pus becomes augmented in 
volume. 

Diagnosis. — Our diagnosis will depend upon the history 
either of a traumatism, or, in idiopathic cases, of symptoms 
characteristic of meningeal inflammation. Examination by 
means of the speculum will reveal the parts in a normal con- 
dition, or, in the case of injury to the head, there may be evi- 
dences of rupture of the membrana tympani ; and it must be 
borne in mind that when these signs are present there is 
more difficulty in determining the actual condition of the 
perceptive apparatus on account of the tympanic complica- 
tion. When no middle-ear lesion exists, a determination of 
the exact portion of the perceptive tract involved depends 
entirely upon the functional examination and upon the ante- 
cedent history. 

Functional Examination. — Where the lesion is labyrinthine, 
the lower tone limit is usually normal, the upper tone limit 
much lowered, bone conduction very slight or absent, while 
the impairment of hearing for the conversational voice is 
relatively less than that for high-pitched sounds. If the lesion 
is so extensive as to cause impairment for the conversational 
voice, this is seldom of a moderate degree, but the deafness is 
almost absolute. Paracusis Willisii is absent. Artificial aids 
to hearing do not improve the auditory power, and the pa- 
tient becomes greatly fatigued after attempting to exert the 
power of audition for any considerable period, the hearing 
becoming rapidly worse, and evidences of severe mental exer- 
tion manifest themselves. The reaction to the galvanic cur- 
rent reveals usually a condition of marked hyperesthesia 
when the lesion is recent. In cases of Ions: standing this con- 
dition may be replaced by one of torpidity. When the trunk 
of the nerve is pressed upon, the upper and lower tone limits 
vary but little from normal. The notes of the middle register 



644 THE PERCEPTIVE MECHANISM IN ACUTE MENINGITIS. 

are poorly heard, and bone conduction is either absent or 
diminished to a marked extent. In testing bone conduction 
in these cases several tuning forks of different pitch should be 
used, since the nerve may react perfectly to forks of one 
pitch while it does not respond to others. The electrical re- 
action shows a persistent hypersesthetic condition, the degree 
of hyperesthesia varying but little on succeeding days, and 
being replaced by one of torpidity in the late stages only. 

When the cortical centre is implicated the presence of tone 
gaps is a characteristic symptom. The most certain evidence 
of involvement of the cortical area, however, is the appearance 
of word deafness. The patient hears isolated sounds, and 
even spoken words, but finds it impossible to repeat spoken 
words or to correctly interpret their meaning. Naturally the 
lesion is bilateral, although the impairment is more marked 
upon the side opposite the involved area. Bone, conduction 
in these cases is diminished, but seldom absent on account of 
decussation of the fibres. The tone gaps may be present in 
any portion of the scale. The galvanic current may reveal 
hyperesthesia or some other deviation from the normal stand- 
ard, such as a reversal of the normal reaction formula, or a 
paradoxical reaction. This latter term is used to designate 
the condition in which stimulation of the organ of one side 
produces phenomena on the opposite side. The concomitant 
symptoms ordinarily are sufficiently marked to confirm the 
diagnosis in cases where cortical involvement is suspected. 

Prognosis. — If we exclude meningitis due to abscess and 
intracranial tumors, the process is not progressive in cases 
where the lesion remains intracranial. In the same manner, 
although to a less degree, an extension to the labyrinth sel- 
dom presents this tendency, the process being limited to the 
immediate area first involved. 

In rendering an opinion, therefore, we may confidently 
state that the hearing will improve rather than diminish as 
age advances. 

Treatment. — In the acute stage our measures of treatment 
are confined to those directed toward meningeal inflamma- 
tion. After the acute stage is past, if the lesion is laby- 
rinthine, the administration of pilocarpine hastens the absorp- 
tion of the effusion within the labyrinth, and causes a rapid 
improvement in function provided complete destruction has 
not taken place. From the well-known action of the iodide 






TREATMENT. 645 

of potassium on recent inflammatory exudates it is well to 
combine this drug with the pilocarpine in moderate doses. 
Where the lesion is intracranial, the administration of iodide 
of potassium for a considerable period in moderate doses is 
probably the best means at our command. Coincident with 
this we may give strychnine in the form of the sulphate or 
nitrate, beginning with small doses and increasing the amount 
to the point of tolerance. It must be remembered that the 
administration of strychnine should not be begun until all 
acute symptoms have disappeared. In cases of intracranial 
involvement the careful and systematic use of some apparatus 
designed to moderately stimulate the auditory nerve by so- 
norous vibrations is of undoubted value. The particular de- 
vice is of but little importance, and may vary from a simple 
conversation tube to a more complicated instrument. It is 
important that the stimulation of the nerve in this manner 
shall not be carried too far, as, where it is too prolonged, the 
function of the nerve is blunted rather than preserved. 



CHAPTER XLII. 

THE EFFECT OF DISEASES OF THE GENERAL NERVOUS 
SYSTEM UPON THE PERCEPTIVE MECHANISM. 

We have already considered the result of the acute in- 
flammatory conditions met with in the meninges, and there 
remains for discussion those affections which are character- 
ized by degenerative changes in the various parts of the 
brain. These are cerebral congestion, apoplexy, cerebral em- 
bolism, endarteritis, cerebral tumors, disseminated sclerosis, 
and tabes dorsalis. From the location of the cortical audi- 
tory centres, and the fact that each auditory centre receives 
fibres from the labyrinth of either side, any cortical lesion must 
be bilateral and extensive to produce absolute deafness upon 
either side. The crossing of the auditory fibres takes place in 
the medulla in the region of the olivary bodies, and an intra- 
cranial lesion upon one side could only produce total deaf- 
ness in one ear when situated between the foramen of exit of 
the auditory nerve and the corresponding olivary body. A 
tumor at the base of the skull might possibly produce this 
effect, but we find that neoplasms seldom occur in this region. 

Investigation of cases of cerebral haemorrhage and of em- 
bolism show that in comparatively few instances is the organ 
of hearing affected to a perceptible degree. Even if the cen- 
tre upon one side is largely destroyed, its place is supplied by 
the corresponding area in the opposite cerebral hemisphere, 
and the impairment in function is but slight. 

The symptom most characteristic of a cortical lesion is 
known as " word deafness." Here words are heard but not 
understood, the patient simply obtaining the general impres- 
sion of sound without being able to interpret it. A subjec- 
tive symptom characteristic of the cortical involvement is 
the presence of certain complex auditory impressions or hal- 
lucinations. The patient seems to hear voices, the conversa- 
tion either being directed to him. or he may simply be the 
listener. Among musicians these hallucinations may assume 

(6 4 6) 



CORTICAL LESIONS— TABES. 647 

the character of well-known musical selections performed by 
an orchestra. The sufferer is able to follow each instrument 
as it performs its special part, and is frequently tormented by 
the impression that one or more is slightly out of tune. The 
exact pathological condition in the cortex exerts but little in- 
fluence upon the symptoms, and may be either congestive, 
hasmorrhagic, degenerative, sclerotic, or neoplastic. Transi- 
tory subjective disturbances of this character are probably 
due to either cerebral congestion or anasmia. The possibil- 
ity of locating a pathological process within the brain itself 
depends upon the presence of associated nervous symptoms 
due to the coincident involvement of contiguous areas, while 
at the same time an examination of the ear reveals the con- 
ducting mechanism to be in nearly a normal condition. 

In tabes dorsalis the changes which have been recognized 
consist in an extension of the sclerotic process to the auditory 
nerve itself, or to its centres. It is characteristic of all affec- 
tions of the acoustic nerve trunk that the electric excitability 
is increased until degenerative changes are so far advanced 
that the function of the ear is entirely lost. A permanent 
hypersesthesia of the nerve, therefore, is strongly indicative 
of intracranial disease if peripheral irritation can be excluded 
in the given case. The portion of the musical scale most 
affected is usually the middle notes of the register, the upper 
and lower tone limits being normal. Where the cortical 
areas are involved the same hypersesthesia may be met with. 
As distinguished from labyrinthine lesion, any change in 
labyrinthine pressure brought about by artificial means, such 
as inflation of the tympanum, will exert but little influence 
upon the perception of sound through the bones of the skull. 
In labyrinthine disease, the disturbance from labyrinthine 
pressure brought about in this way usually diminishes bone 
conduction. It is also to be remembered that until a high 
degree of atrophy has been reached bone conduction is pre- 
served when the symptoms are due to an intracranial growth.* 

In discussing the symptoms in the previous pages we 
have confined ourselves to the hypothesis that the intra- 
cranial process was confined to the cerebrum. When the 
cerebellum is involved, disturbance of equilibrium occurs, to- 
gether with nausea, while there may be no impairment in the 

* Politzer, Diseases of the Ear, American edition, p. 587, 



648 EFFECT OF DISEASES OF THE NERVOUS SYSTEM. 

hearing. Changes in the trunk of the nerve may give rise to 
disturbances of equilibrium, as well as to subjective noises 
and impairment of hearing. 

Practically the diagnosis in these cases depends more 
upon the associated symptoms characteristic of the general 
nervous affection than upon the aural manifestations. The 
absence of any evident condition within either the conduct- 
ing mechanism or labyrinth which is capable of producing 
the symptoms, while at the same time the evidence of the 
general nervous affection is marked, is the chief aid to diag- 
nosis. 

Regarding medication but little can be said. The chief 
indications for treatment will be furnished by the general 
nervous disease. If the aural symptoms are pronounced, 
they should be treated according to the directions already 
given. For the subjective noises the bromides will usually be 
found most efficacious. If there are evidences of faulty nutri- 
tion of the nerve tissue, strychnine in large doses will often be 
of benefit in preventing the total loss of function. From the 
possibility of a specific taint large doses of the iodide of po- 
tassium should be given in any case if there is evidence of 
intracranial involvement. 



SECTION VI. 

COMPLICATING AURAL DISEASES. 



43 



COMPLICATING AURAL DISEASES. 



CHAPTER XLIII. 

AURAL AFFECTIONS COMPLICATING THE ACUTE INFECTIOUS 

DISEASES. 

We have already considered the changes which may take 
place in the perceptive portion of the auditory mechanism 
from the acute infectious diseases. In addition to these, the 
conducting apparatus is a frequent site of pathological condi- 
tions from the same cause. In a majority of cases the acute 
infectious disease produces an inflammation of the middle ear 
when this organ of special sense is in any way involved. It 
may be stated, as a general rule, that the severity of the inflam- 
mation within the tympanum corresponds in degree to that of 
the exciting cause. Thus, in the milder exanthemata — such as 
measles, varicella, mild influenza, and in mumps — an affection 
of the middle ear is usually confined to the lower portion of the 
cavity, constituting either a tubal catarrh or an acute catar- 
rhal otitis media. If rupture of the drum membrane takes 
place, the discharge is serous or sero-mucous in character, 
and only becomes purulent by infection from without. In the 
more severe infectious diseases — such as severe cases of rubeola, 
scarlatina, variola, typhus fever, and diphtheria — the infection 
is more virulent, and here the connective-tissue structures are 
the chief seat of involvement. In other words, the otitis 
media, which complicates the diseases just named, has its 
origin in the upper portion of the tympanic cavity, and con- 
stitutes in reality a cellulitis. This cellulitis follows the course 
typical of such a process in any portion of the body, and very 
quickly results in extensive tissue necrosis, the soft structures 
breaking down with the formation of pus, while after a com- 
paratively short interval the contiguous bony structures be- 
come affected and rapidly disorganize. It is probable that in 

(651) 



652 COMPLICATIONS OF ACUTE INFECTIOUS DISEASES. 

a given case the selection of the lower or upper portion of the 
tympanic cavity as the seat of process depends entirely upon 
the degree of infection rather than upon the selection of any 
particular region by various organisms, the lower portion 
being involved in the milder cases, while the upper part is 
attacked in the more severe forms of infectious disease. Bac- 
teriological investigation goes to show that the germ charac- 
teristic of the particular disease is not so much the cause of 
the otitis media as are the bacteria of suppuration, and that 
the number of these last-named germs present depends en- 
tirely upon the degree of systemic infection. 

It may seem that this line is rather sharply drawn, as 
many cases present in which at first it is almost impossible to 
reconcile clinical experience with this theory. A careful study 
of many cases has convinced me that where these anatomical 
boundaries are transgressed this departure is always marked 
by a corresponding change in the general symptoms of the 
patient. Thus in epidemic influenza of a mild type, or in a 
mild case of measles, we should expect the lower portion of 
the tympanum to be involved, the characteristic signs being a 
comparatively slight amount of pain in the ear, of short dura- 
tion, and quickly followed by the effusion of serum or sero- 
mucus. Where the quantity of fluid is not sufficient to cause 
rupture of the membrana tympani the fluid may remain in the 
middle ear for a considerable length of time. During this 
period the temperature will remain moderately elevated, or 
may reach normal if the process is entirely quiescent. Sud- 
denly the temperature rises rapidly, the patient exhibits con- 
siderable prostration, and the pain in the ear returns. An 
examination will now reveal that, in addition to the effusion 
already present in the lower portion of the tympanic cavity, 
there are unmistakable evidences of involvement of the vault. 
The fluid in the middle ear is a culture medium which favors 
the development of pathological bacteria, and if these are still 
present, invasion of the upper portion of the cavity may take 
place at any time. In the same manner those cases where 
the process at first seems confined to the upper portion of the 
cavity, but does not go on and rupture through Shrapnell's 
membrane, may remain quiescent for several days, the tem- 
perature becoming normal and the pain in the ear disap- 
pear, although the local manifestations, such as redness above 
the short process and above the anterior and posterior liga- 



SYMPTOMATOLOGY. 653 

ments, still continues. A sudden rise of temperature, with 
pain in the affected organ, is accompanied by a bulging of the 
entire posterior quadrant, and a rapid extension of the redness 
to the region of the membrana vibrans. Here the products of 
inflammation have passed into the atrium, following the long 
process of the incus ; and the involvement of the atrium is to 
be looked upon as a secondary infection, giving rise to distinct 
symptoms. It is scarcely necessary to call to mind the clinical 
importance of the facts already stated when we remember 
that any inflammation in the upper portion of the tympanic 
cavity always constitutes a disease of considerable gravity, 
and one which demands prompt measures for its relief, while 
an inflammation of the atrium is comparatively simple if we 
can confine it to this region. According, then, as our gen- 
eral disease is mild or severe, we may predict with consider- 
able certainty a corresponding degree of aural involvement. 
The exact method of dealing with these conditions has already 
been sufficiently dilated upon. 



CHAPTER XLIV. 

AURAL AFFECTIONS DEPENDENT UPON CHRONIC VISCERAL 

CONDITIONS. 

In general, we may state that any changes within the vis- 
cera produce disturbances referable to the ear chiefly from 
their effect upon the general venous circulation. Where the 
venous flow through the larger viscera is obstructed, a dam- 
ming back of the return current from the internal ear results, 
leading in time to a dilatation of the venous channels within 
the auditory apparatus. This is particularly true of the laby- 
rinth, and, as already mentioned, constitutes a common cause 
of labyrinthine congestion. Within the middle ear or within 
the meatus corresponding changes may occur, as evidenced 
by an increased vascularity in the parts and a greater tor- 
tuosity of the minute veins. 

Nephritis. 

In nephritis, the pathological conditions found in the organ 
of hearing depend both upon the obstruction to the general 
venous circulation and also upon that condition of the arteries 
so frequently met with, known as arterio-capillary fibrosis. 
As the result of these changes within the vessel walls, the tis- 
sues are poorly supplied with blood, the result being that the 
entire economy is in a condition below the normal standard 
of health. The quality of the blood circulating within the 
vessels is also impoverished, its fluid elements being relatively 
increased. 

Within the tympanum these changes in the vessels and in 
the quality of the blood frequently result in a transudation 
of serum through the vessel walls, the lesion being similar to 
that of pleural effusion in nephritis. This condition should 
not be looked upon as an inflammation, although it is fre- 
quently called otitis media serosa. The process is entirely 

(654^ 



NEPHRITIS— METASTASIS. 



655 



mechanical, and the fluid is the result of transudation, and 
not of an inflammation. The fluid within the cavity may be 
absorbed spontaneously, or may remain for an indefinite pe- 
riod. When the middle ear is in this condition it is more 
liable to become the seat of a mild catarrhal inflammation 
than under normal conditions. Coincident with the effusion 
there is usually a partial or complete stenosis of the Eusta- 
chian tube, due to passive congestion of the lining membrane, 
with a diminution of atmospheric pressure within the middle 
•ear. This change favors the passage of fluid from the blood 
vessels into the tympanic cavity, and the process tends to effect 
permanent changes. From the weakness of the vessel walls 
rupture is not uncommon, and haemorrhagic otitis media, or, 
more properly, haemato- tympanum, is occasionally found. 
These haemorrhages may also occur in the external auditory 
canal, or between the layers of the drum membrane itself. 
Similar changes may take place within the labyrinth, in one 
case causing an increase in labyrinthine pressure either by an 
augmentation in the quantity of perilymph or by actual haem- 
orrhage into the labyrinthine channels. In the latter instances 
the extravasation of blood may destroy the end organ of the 
auditory nerve over a given area, rendering it useless and inca- 
pable of performing its function. This will lead to absolute 
deafness to the particular sound which this portion of the 
cochlea perceived. Haemorrhagic changes in the sheath of 
the auditory nerve may also complicate a chronic nephritis. 
The blood supply of the labyrinth is derived from several 
channels, and hence the occlusion of one of these efferent 
vessels might take place without seriously impairing the func- 
tion of the part, the blood supply being maintained through 
the collateral circulation. 

Metastasis. 

An extensive suppurative process in any portion of the 
body, such as an acute osteomyelitis or bony caries, or necro- 
sis located in any region, may be the point of origin of infec- 
tious emboli. These are carried through the various circula- 
tory channels, either into the middle ear or labyrinth, and 
their lodgment produces symptoms dependent upon the shut- 
ting off of the blood supply of the parts beyond, or by a local- 
ized secondary infectious process which they excite. It is 
not improbable that chronic suppuration within the accessory 






656 COMPLICATIONS OF CHRONIC VISCERAL LESIONS. 



sinuses of the nasal cavity is responsible for many obscure 
aural symptoms met with in these cases. The entrance of an 
embolus into the blood current from one of the accessory si~ 
mises, and its subsequent passage into the labyrinthine vessels, 
is the most plausible explanation of the cases of mild tinnitus 
and sudden impairment of hearing of moderate degree which 
are frequently met with. In ulcerative endocarditis, an in- 
fection either of the internal, middle, or external ear may 
take place in the same manner, from a detachment of the vege- 
tations on the cardiac valves. 

In acute pulmonary affections, particularly pneumonia, an 
acute middle-ear inflammation may result from the passage 
of the infectious germ through the blood current and its 
lodgment in the tympanic mucous membrane. It is probable 
that certain cases are due to the entrance of germs through 
the Eustachian tube. The degree to which the middle ear is 
involved will depend upon the severity of the pulmonary 
process ; if this is severe, the aural inflammation will be sup- 
purative, while in the milder cases it is a simple catarrhal 
inflammation, or may cease spontaneously at the stage of con- 
gestion. 

Tuberculosis. 

In tuberculosis, the involvement of the middle ear is char- 
acterized by the insidious manner in which the infection de- 
velops, frequently the first symptom which the patient recog- 
nizes being discharge from the ear, there having been no 
pain or noticeable impairment of hearing previous to this 
time. On examination, the entire drum membrane may be 
wanting, and in some cases the ossicula themselves may have 
become involved. Where the destruction of the membrane 
has taken place over a limited area the perforation presents 
a somewhat characteristic appearance. It is usually circular, 
the edges are thick and everted, and present, instead of the 
bright-red color commonly observed in a simple perforation 
of the membrana tympani, a blue-white, glossy, cedematous 
appearance comparable to that seen over the arytsenoid car- 
tilages in laryngeal tuberculosis. Another condition which 
is somewhat characteristic is the appearance of two or more 
distinct perforations in the membrane. Where the ossicles 
are involved, the surrounding bony structures are quickly 
attacked, and the entire mastoid may be broken down even 



TUBERCULOSIS— LEUCAEMIA. 657 

at a very early period. It is important to recognize the dis- 
ease in its incipiency, as prompt removal of the affected parts 
may check the progress and relieve to a degree the sys- 
temic condition dependent upon it. Usually, when the organ 
of hearing is attacked, the pulmonary or visceral involvement 
is an affair of so much greater gravity than the aural affec- 
tion as to make this latter insignificant. If, from the severity 
of the symptoms, or in the hope of stopping the progress 
of the affection it is deemed advisable to attack the local 
lesion, we should remember that any operative measures will 
be greatly aided by the administration of those drugs which 
seem to exert a specific influence upon the tubercular pro- 
cess. 

The nutrition of the patient should be particularly at- 
tended to. Cod-liver oil, the hypophosphites, and the vari- 
ous preparations of malt are all of value in the various cases, 
and much is to be said in favor of the administration of creo- 
sote in doses of one half to three grains three or four times 
daily. While I do not wish it to be understood that the tym- 
panic lesion demands treatment in a large majority of cases, 
or that radical treatment directed to this part is advisable, it 
is well to bear in mind the possibility of systemic infection 
from this focus, and also the fact that the local process is sure 
to extend rapidly, and is hence more easily checked in its 
early stage than after it has existed for a considerable period. 

Leucaemia. 

In leucaemia a form of deafness is found depending upon 
the passage of minute cells or lymph corpuscles into the laby- 
rinthine channels (Fig. 158), narrowing their calibre and in 
time even leading to a complete obliteration of their lumen. 
In the early stages this deposit is cellular in structure ; but if 
the patient survives the disease for a long time, organization 
of this tissue may take place, and the obliteration of the laby- 
rinthine passages is effected by an osseous deposit, the symp- 
toms depending upon the extent of the local process and upon 
its severity. It is recognized by the presence of the gen- 
eral leucaemic condition, and with the sudden appearance of 
deafness which gradually grows worse, together with vertigo. 
nausea, and subjective noises. The functional examination 
reveals a lesion of sound-perceiving apparatus rather than one 



658 COMPLICATIONS OF CHRONIC VISCERAL LESIONS. 

referable to those parts concerned in sound transmission. 
Practically nothing can be done to stay the progress of the 
affection, our efforts at treatment being as futile as those em- 
ployed to combat the constitutional affection. 








1 



C.E. 



N.F. 
Fig. i 5 8.-Section through the middle turn of the cochlea in a case of leucaemia, 
showing infiltration (Gradenigo .*) O, Bone ; S. V., Scala vestibuli ; S. T. 
bcala tympani; Z. S Ligamentum spiralis; A.V. y Stria vascularis; N. F 
^erve expansion m the lamina spiralis; e, f, g, Membrana tectoria • h, Inner 
riair-cells ; m, n, Corti s rods ; a, I, d, Limbus lamina spiralis ; /, Epithelium of 
sulcus spiralis mternus ; p, Epithelium of sulcus spiralis externus ; C. £., Outer 
cells of Corti and Deiter ; c, c, /, Claudius's cells ' 



* Arch, fur Ohrenheilk , vol. xxiii, p. 242. 



DIABETES— GOUT— RHEUMATISM. 



659 



Diabetes. 

In severe cases of diabetes the most characteristic affec- 
tion referable to the ear is the occurrence of acute circum- 
scribed external otitis. When we remember how prone the 
diabetic patient is to furunculosis, we can explain the occur- 
rence of the aural lesion upon the same ground. Eczema of 
the auricle and canal is also of common occurrence. Within 
the tympanum there is scarcely any condition characteristic 
of diabetes, although it is probable that all structures, includ- 
ing those of the middle ear, are more liable to attacks of in- 
flammation than under normal conditions. Symptoms refer- 
able to the sound-perceiving apparatus probably depend upon 
either labyrinthine haemorrhage or extravasation into the me- 
dullary or cortical centres. The repair of any lesion sponta- 
neously is slow in these cases. When the condition is an 
acute inflammatory one, suppuration is the rule. This is 
worthy of note where the mastoid process becomes involved 
consecutive to an inflammation within the canal or middle 
ear. Often, in spite of the greatest precaution, prolonged 
suppuration occurs ; and while we should not be deterred 
from operating upon diabetic patients for this reason, efforts 
to secure perfect asepsis must be vigorously enforced. 

Gout and Rheumatism. 

Gout and rheumatism probably exert a greater influence 
upon the organ of hearing than is usually supposed. It is 
not necessary that the patient shall have ever been the victim 
of an acute gouty or rheumatic attack, the hereditary diathet- 
ic condition being sufficient to induce pathological changes 
within the ear. While the cases dependent upon gout or 
rheumatism as the sole cause are probably rare, any acute or 
chronic inflammatory process arising from some other cause 
is modified to a marked degree through these diatheses. 
Thus in numerous cases of nonsuppurative otitis media our 
measures for relief may be without result until internal medi- 
cation is directed toward the correction of the gouty or rheu- 
matic taint. In the canal itself a persistent eczema rather 
mild in character is frequently met with in patients suffering 
from a gouty diathesis. Although in itself this inflammation 
would scarcely attract the attention of the patient, it leads to 
a condition of the cutaneous lining of the canal which favors 



660 COMPLICATIONS OF CHRONIC VISCERAL LESIONS. 

the development of vegetable parasites. When these have 
once gained lodgment in the meatus, the local inflammation 
which they excite by their presence is sufficient to produce 
marked symptoms from which the patient seeks relief. 

Treatment of the local condition will probably be without 
avail unless the gouty diathesis is at the same time borne 
in mind and combated. In the tympanum itself we find in 
rare instances an inflammation of the interossicular articula- 
tions which is probably rheumatic in nature. The local ap- 
pearances are confined to the immediate region of the articu- 
lation. The pain is severe, the constitutional disturbance 
marked and out of proportion to the local lesion, and efforts 
to afford relief are unsuccessful until antirheumatic drugs are 
administered. The symptoms abate under this plan of medi- 
cation, and the disease follows the course of an acute articu- 
lar rheumatism of any of the larger joints. It was formerly 
supposed that the gouty diathesis exerted a peculiar influence 
upon the development of exostoses within the bony meatus, 
but this theory has not been borne out by subsequent investi- 
gation. Of much more importance is the influence which 
this diathetic condition exerts upon the walls of the blood 
vessels. Arterial degeneration takes place, the vessels be- 
coming rigid through the deposit of lime salts in their walls,, 
thus narrowing the calibre and so weakening the walls that 
they are easily ruptured by any sudden increase in blood 
pressure. These effects are most marked within the labyrinth,, 
and give rise to subjective noises, giddiness, and slight im- 
pairment in hearing. In advanced cases the occurrence of 
capillary haemorrhages also serves to explain many of the 
symptoms met with. 

Medicinal Substances. 

The ingestion of certain medicinal substances exerts a 
specific influence upon the organ of hearing. Of these, the 
most prominent is quinine. Salicin, salicylic acid and its 
salts exert a similar influence in a less degree. In general 
these changes constitute in mild cases a congestion both of 
the middle ear and of the labyrinthine structures. When any 
drugs of this character are administered in excessive doses 
this hyperaemia may lead to rupture of the vessels, causing 
minute haemorrhages. When administered for a long period, 
even in moderate doses, the chronic congestion produces 



MEDICINAL SUBSTANCES. 66 1 

structural changes particularly within the labyrinth, which 
do not disappear even after the administration of the drug is 
stopped. When the ear is in a normal condition it is probable 
that serious injury following the exhibition of these drugs is 
comparatively rare ; but where the ear is the seat of a chronic 
inflammatory process, or is particularly susceptible to cir- 
culatory changes, their use is to be guarded against. It is 
manifestly impossible to prevent the use of these remedies in 
all cases of chronic aural disease, but they should never be 
given except in an extremity, and then should be exhibited 
in small doses, and discontinued as soon as possible. The 
habit of prescribing large doses of quinine for a cold in the 
head can not be too strongly prohibited. 

The moderate use of tobacco influences the organ of hear- 
ing but slightly, whether the parts are in a state of health or 
disease. It was formerly supposed that its use aggravated 
any pre-existing catarrhal inflammation of the upper air tract, 
and in this way aggravated chronic affections of the tym- 
panum. The danger in the use of tobacco does not lie in 
this direction, but rather in the effect which the drug exerts 
upon the general nervous system. If the habitual use of to- 
bacco produces constitutional disturbances referable to the 
general nervous system, there is no question about the advis- 
ability of stopping it at once. That it should exert any spe- 
cific action upon the organ of hearing, while the general 
nervous organism escapes, is exceedingly improbable. We 
may practically disregard any action upon the conducting 
mechanism ; and if the receptive portion of the auditory sys- 
tem suffers from its habitual use, we shall have confirmatory 
evidence from its effect upon other portions of the nervous 
system. The particular region of the perceptive tract af- 
fected is probably either the nerve trunks or centres them- 
selves. 






CHAPTER XLV. 

DISTURBANCES OF AUDITION DEPENDENT UPON FUNCTIONAL 
NERVOUS DISORDERS. 

The most common functional disturbances of the nervous, 
system which produce any marked effect upon the organ of 
hearing are those known under the terms " neurasthenia " 
and " hysteria." 

Since the exact nature of these conditions is at present 
problematical, the manner in which they influence the vari- 
ous portions of the sound-perceiving mechanism is a mat- 
ter of conjecture. In certain instances neurasthenic or hys- 
terical patients will present marked disturbances referable to 
the organ of hearing. These disturbances probably depend 
upon some slight pre-existing pathological condition which 
ordinarily would pass unnoticed. The lesion may lie either 
in the meatus or in the tympanic cavity, and be entirely un- 
recognizable upon careful examination ; but as it constitutes 
the point of least resistance in the nervous system, the mani- 
festation of a neurasthenic or hysterical condition is exhibited 
here rather than in another locality. The reason for believing 
this, is that where a moderate affection of the sound-conduct- 
ing mechanism exists, the disturbance of function is out of all 
proportion to the pathological condition present ; and in addi- 
tion to these symptoms, which are characteristic of involve- 
ment of the transmitting apparatus, certain other manifesta- 
tions present which can only be explained by the abnormal 
general condition. 

Neurasthenia. 
In neurasthenia the entire nervous system seems to be 
overtaxed by even a moderate effort ; and where the function 
of any one organ is impaired, as in the cases under considera- 
tion—the organ of hearing— this impairment is magnified to a 
great degree. In general these cases are characterized by 
the symptom which may be termed " auditory strain." In 

(662) 



NEURASTHENIA. 663 

conversation with one individual the patient hears fairly well, 
and the hearing is usually better early in the morning. After 
being subjected to the fatigue consequent upon the day's ac- 
tivity, the hearing power becomes much diminished, and any 
effort on the part of the patient to disguise the symptom 
simply magnifies it. The local impairment, in turn, reacts 
upon the general condition of the patient to a considerable 
degree, frequently causing him to become hypochondriac, 
and in some cases leading to acute melancholia. The hearing 
is more impaired in a noisy than in a quiet room ; tinnitus is 
present, and varies greatly in degree, being more marked 
when the patient is tired. In addition to these subjective symp- 
toms, certain others manifest themselves, such as a feeling of 
formication in the canal ; a feeling of occlusion in the meatus, as 
though a foreign body were present ; or a sensation of irritation 
referred either to the Eustachian orifice or to the base of the 
tongue. Often during the process of examination the hear- 
ing fluctuates greatly. If patients can be convinced that no 
test is being made, they frequently respond to questions 
asked in a moderate tone of voice ; as soon, however, as they 
become aware that the power of audition is being estimated 
their anxiety to hear causes a marked diminution in the 

power. 

Diagnosis.— As said before, certain deviations from the 
normal standard may be found upon speculum examination, 
or these departures from the normal may be so slight as to 
be entirely overlooked. Functional examination is a matter 
of considerable difficulty, especially if any recognized lesion 
of the conducting apparatus is present, the answers of the pa- 
tient being very misleading unless the general condition is 
borne in mind. As a rule, low tones are well heard, the low- 
est limit of the scale being frequently preserved, even where 
inspection shows a marked alteration in the conducting 
mechanism. The upper tone limit may be moderately low- 
ered, but is occasionally elevated, and the high notes may be 
painful. Bone conduction is diminished, while sharp sounds, 
such as the tick of a watch or the click of the acoumeter, give 
varying results, being heard at one time exceedingly well at 
another time poorly or not at all. The voice is usually heard 
better relatively than either the watch or acoumeter. 

The most valuable aid in diagnosis is a comparison of 
the results obtained by functional examination with the gen- 



664 INFLUENCE OF FUNCTIONAL NERVOUS DISEASES. 

eral history of the case. When we consider the undue im- 
portance which these patients attach to the slight subjective 
symptoms of which they complain — referable to the meatus, 
the vault of the pharynx, or region of the Eustachian tube 
— we can readily understand why the results of functional 
examination should be so at variance with what might be 
expected. 

The hyperacusis which is quite commonly observed in 
these cases explains the preservation of the lower tone limit 
even when this should be considerably elevated. We are 
apt to be misled also by this symptom, for quantitative 
tests may yield entirely negative results, the patient hear- 
ing the watch, acoumeter, or whispered speech at the normal 
distance. Continuing the examination for some time, we 
shall usually find that the organ soon becomes tired and the 
hearing power rapidly diminishes. This fatigue manifests 
itself not only for any one sound, but when this condition is 
reached all sounds are poorly perceived. This, we must re- 
member, is a marked deviation from the normal standard. 
In health, although the sonorous vibrations of any given 
pitch will, after a time, so fatigue the perceptive centres as 
to reduce the power of audition for that particular sound, 
yet this impairment of function does not invariably occur 
with the perception of sounds of different pitch, but rather 
renders the hearing of them more acute. In order to test 
the ease with which the ear is fatigued it is only necessary 
to make use of a tuning fork of 512 V. S., or the octave 
above this, and maintain the fork in vibration close to the ear 
for a period of five to ten minutes, setting it in vibration 
anew as soon as its note becomes weak. If the fork is struck 
with approximately equal force each time, it will be found 
that the period during which its vibrations are perceived will 
become shorter and shorter. In some cases we find that the 
ear very quickly ceases to perceive the note of the fork. If 
now the instrument is removed from the ear for a few sec- 
onds, and then again brought immediately in front of the 
meatus, the note will again be heard, although the instru- 
ment has not been set in vibration afresh, and hence the 
sound is less intense than when it was removed from in front 
of the ear. This is called a secondary perception of the note. 
In marked instances we find even tertiary or quaternary 
perceptions. This phenomenon corroborates the statement 



TREATMENT OF NEURASTHENIA— HYSTERIA. 665 

•of the patient that the power of audition is poorest in listen- 
ing to general conversation. 

Prognosis. — Aside from any organic changes which may 
be present either in the middle ear or labyrinth, the prog- 
nosis will depend upon our ability to control the general 
nervous condition. This is difficult, and the outcome of such 
a case must always be uncertain. If the patient can be per- 
suaded to think less about his hearing, there is fair hope that 
the power of audition will improve. 

Treatment. — No drugs exert a specific action upon the 
central portion of the auditory apparatus in this condition, 
and the treatment of defective hearing will resolve itself into 
the treatment of neurasthenia. Strychnine in large doses, as a 
nerve tonic, is of use in a considerable proportion of cases. 
Where the strychnine increases the excitability of the pa- 
tient, this may be controlled by the administration of bro- 
mide of sodium in proper doses at the same time. We thus 
overcome the reflex excitability produced by the first drug, 
while we in no way diminish its action as a nerve tonic and 
as a stimulant to the nervous centres. A complete change 
of scene is advisable, and where the disease has resulted 
from prolonged mental exertion it is well to interdict work 
of this kind. This is by no means an absolute rule, as a con- 
siderable proportion of patients do not improve unless their 
minds are occupied in some manner. A complete change of 
occupation is desirable in these cases, since they may become 
so interested in their work as to forget themselves, and thus 
second our efforts in restoring their normal condition. 

Hysteria. 

This affection is closely allied to the one just described, 
and frequently accompanies it. Why, in a given case of hys- 
teria, symptoms referable to the ear are paramount, can be 
explained only on the ground already given in considering 
the effects of neurasthenia — that in these cases the ear is the 
point of least resistance. 

Symptomatology. — Impairment in hearing varies greatly 
in degree, but is usually profound, and the patient may be 
completely deaf. The deafness comes on suddenly, as a rule, 
quite frequently as the result of some severe mental shock, 
and possesses the peculiar characteristic of preserving the 
original degree of impairment throughout the entire history 



666 INFLUENCE OF FUNCTIONAL NERVOUS DISEASES. 

of the case. The condition neither improves gradually nor 
does it grow worse. Complete restoration of function may 
take place from no assignable cause, and may occur quite as 
suddenly as the power of hearing disappeared. 

Another curious symptom is the so-called transference of 
the lesion from one side to the other. For a certain length 
of time the organ of one side alone will seem to be perfectly 
deaf. Suddenly the hearing will be restored upon this side, 
but at the same time the organ of the opposite side becomes 
affected. This change may be repeated any number of times. 
Pain is quite commonly complained of in the region of the 
ear, it being located either deep in the meatus or in the mas- 
toid process. Occasionally this pain is referred to the phar- 
yngeal vault, although this is not common. Giddiness and 
subjective noises are usually absent, the case thus presenting 
a marked contrast from one dependent upon neurasthenia. 
Where other symptoms of a hysterical nature are present, 
such as hemiansesthesia or hemiplegia, the defective ear is 
usually on the side of the body presenting the sensory or 
motor impairment, although this is not invariable. 

Diagnosis. — The above phenomena may be observed where 
to all appearances the organ is perfectly healthy, or we may 
find, upon examination, evidences of a preceding suppurative 
or nonsuppurative process. The eye alone aids us very little 
in making a correct diagnosis. Much information, however r 
may be obtained by testing the sensitiveness of the meatus 
and drum membrane by means of the probe, the parts being 
quite frequently anaesthetic. Functional examination, also, 
may reveal nothing characteristic, although in quite a num- 
ber of cases we find that both the upper and lower limits of 
the scale are poorly perceived, the lower tone limit being 
elevated, while interference with the upper tone limit seems 
to be more common than with the lower, the high notes be- 
ing but poorly heard, as a rule. This reduction of the upper 
tone limit is distinct, usually extending as low as 4 or 6 of the 
Galton scale. 

A symptom frequently met with in an examination is the 
alternating perception of the high notes first on one side and 
then on the other. Upon one side the upper tone limit 
will be found greatly reduced, while the organ of the oppo- 
site side will perceive the highest tones of the scale with 
ease. On repeating the experiment, the condition will be 



HYSTERIA— PROGNOSIS— TREATMENT. 66y 

exactly reversed, and this alternation may be repeated several 
times during the examination. 

The occurrence of other hysterical manifestations affords 
confirmatory .evidence. This is particularly true if the field 
of vision is investigated, since in most cases this is uniformly 
contracted. 

Prognosis. — It is absolutely impossible in a given case to 
render an intelligent opinion as to the recovery of the hearing. 
It is a well-known fact that in hysteria many of the symptoms 
may completely disappear, while the others remain unabated ; 
and we also note that interference with any special sense is a 
symptom which does not disappear readily. 

Treatment. — Those drugs administered for the control of 
hysteria are indicated in these cases. Valerian, either in the 
form of the simple tincture or the ammoniated tincture, is 
often of value. The same is true of asafcetida, the bromides, 
various preparations of zinc, phosphorus, hyoscyamus, galba- 
num, etc. 

Hypnotic treatment is probably of more value in these 
cases than any other, and is always worthy of a trial. It 
should never be forgotten that hysteria is a disease, and that 
the patient is not malingering ; hence severe measures are 
worse than useless. Curious instances have been reported 
of the complete disappearance of the deafness upon bringing 
a magnet close to the ear. By this same means it has also 
been possible to transfer the condition to the opposite side. 



CHAPTER XLVI. 

REFLEX AURAL DISTURBANCES. 

A pathological condition in any portion of the body 
may produce within the organ of hearing, not only alterations 
of function, but also certain visible changes. While we are 
familiar with the precise mechanism by which motor reflexes 
are brought about, those of a sensory or trophic character are 
as yet obscure. The most plausible view is, that under the 
reflex stimulus certain changes take place in the vascular sup- 
ply of the part affected, through the action of the vasomotor 
nerves, and that capillary dilatation is responsible for the phe- 
nomena produced. In the conducting portion of the organ of 
hearing the deviations from the normal standard are of such 
a nature as to be visible to the eye, while in the nervous ap- 
paratus subjective symptoms are the only indication of any 
change from the standard of health. Changes which take 
place in the auricle from reflex action may cause an abnormal 
redness or congestion of the part ; or, if the capillaries are 
constricted, the blood supply will be diminished, the ear ap- 
pearing pale and bloodless. When the trophic nerves are in- 
terfered with, a cutaneous eruption may occur, the most com- 
mon of which is herpes, the auricle being covered by small 
vesicles at first discrete, but by coalescence forming bullae. 
The symptoms have already been described by herpes of the 
auricle. 

Within the canal a circumscribed external otitis may de- 
pend upon a reflex cause, the pathological lesion producing it 
being most frequently a corresponding condition upon the 
opposite side. Hypersensitive areas may also develop in the 
meatus, usually in the bony portion and upon its floor, the 
region being excessively tender to the touch of the probe, 
while ocular inspection either reveals no deviation from the 
normal condition, or only a minute erosion at the tender point. 
In some instances periodical attacks of bleeding from the 

(668) 



TYMPANUM— PERCEPTIVE MECHANISM. 669 

meatus occur, depending upon changes in some remote organ 
of the body. 

Within the tympanum a reflex stimulus may cause a tran- 
sudation either of blood or serum ; in either case the quan- 
tity of fluid may be so great as to cause rupture of the mem- 
brana tympani. Instances of otitis media of a reflex character 
have also been observed. Pain in or about the ear in a vast 
majority of cases depends upon some local inflammatory pro- 
cess. It is occasionally met with where no inflammatory pro- 
cess presents upon the most careful examination. In children 
particularly, a reflex otalgia often occurs, depending either 
upon the eruption of the molars or upon early dental caries. 
This latter condition is occasionally the cause of an inflamma- 
tory affection of the middle ear, either acute or chronic. A 
symptom of rare occurrence is a periodical oedema over the 
mastoid process, accompanied by exquisite pain and tender- 
ness. I have observed one instance of this in which acute 
middle-ear inflammation was complicated by this angioneurotic 
cedema ; considerable difficulty was experienced in arriving at 
a correct diagnosis, and the question of the advisability of open- 
ing the mastoid was seriously debated. All reflex disturb- 
ances, particularly those of a painful character, are most fre- 
quently met with in females of a neurotic or hysterical type. 

When we come to consider the perceptive tract, cases of 
anaesthesia or paresthesia are by no means uncommon. A 
moderate impairment of hearing may be the result of visceral 
disturbances, particularly of the pelvic viscera, while tinnitus 
resulting from constipation, subacute gastritis, a pathological 
condition within the pelvis, etc., is of common occurrence. 
An interference with the statical function of the ear is proba- 
bly the most familiar example of reflex excitation of the 
auditory perceptive apparatus. The giddiness so common in 
disorders of digestion is without doubt dependent upon 
stimuli conveyed to the auditory nucleus in the medulla 
through the vagus nerve, the vagus centre lying close to the 
nucleus of the vestibular nerve. It is probable that here the 
condition is one of increased vascularity from capillary dilata- 
tion. Reasoning in this manner, we are able to explain irreg- 
ular attacks of impairment in the hearing of short duration, 
accompanied by intense subjective noises, by supposing that 
a similar disturbance has taken place either in the medullary 
centre of the cochlear nerve or in the cortical auditorv cen- 



6; REFLEX AURAL DISTURBANCES. 

tre itself. The symptom which leads us to suspect that any 
functional disturbance of the ear is dependent upon a reflex 
cause is the irregular appearance of the symptoms, and their 
sudden and complete subsidence, often from no apparent 
cause. Structural changes necessitate a certain permanency 
of the manifestation ; and where this does not occur we can 
only explain the condition by supposing that the centres have 
been irritated by a temporary increase in the blood supply. 

If now a thorough examination of the patient reveals a re- 
mote lesion, particularly if it is located in a region where or- 
ganic changes are prone to excite reflex symptoms, we should 
bear in mind that such reflex symptoms may be quite as well 
referred to the organ of hearing as to any other portion of the 
body. We can not too strongly emphasize the necessity of a 
thorough physical examination in every obscure case ; in other 
words, the otologist should locate subjective phenomena in 
the ear rather by exclusion than otherwise. 

We have already spoken of those regions of the body where 
any specific change is particularly liable to exert a reflex in- 
fluence upon either the centres of audition or the terminal 
apparatus of the auditory nerve. To this list we must add the 
opposite ear, since lesions of an inflammatory character, or in- 
juries to the organ of one side, may produce not only tempo- 
rary but often permanent changes in the opposite organ. 
The augmentation of the perceptive power observed when 
the opposite organ of hearing is subjected to sonorous vi- 
brations has already been alluded to. Another familiar ex- 
ample is the effect of condensing the air in the auditory 
meatus, while at the same time a sounding body is held close 
to the opposite ear. If this experiment is tried, we find that 
the sudden condensation of air diminishes the perceptive 
power of the opposite organ. Here it is supposed that the 
path of the reflex current lies through the upper portion of 
the cervical cord, and the test is used to demonstrate the 
integrity of this portion of the central nervous system. The 
experiment is of much greater value from a clinical point of 
view in explaining the occurrence of subjective noises re- 
ferred to one side, in which an examination of the ear reveals 
nothing abnormal. Examination of the opposite side fre- 
quently reveals either a narrowing of the Eustachian canal, 
the presence of impacted cerumen, or a marked pathological 
process within the tympanum, and the subjective symptoms 



DIAGNOSIS— PROGNOSIS— TREATMENT. 67 1 

do not disappear until the pathological condition in the op- 
posite ear is removed. 

Diagnosis. — The recognition of the reflex nature of these 
symptoms then depends upon their occurrence in an appar- 
ently healthy organ, and next upon the discovery of some 
remote pathological condition which may act as an exciting 
cause. A valuable confirmatory sign is that afforded by an 
examination with the galvanic current, a condition of marked 
hyperaesthesia usually being found. If we can exclude with 
certainty an active process within the middle ear or within 
the cranium itself, the auditory hyperaesthesia must be reflex ; 
and if the cause does not lie in the opposite ear a remote lesion 
alone can explain it. 

Prognosis. — Our ability to correct these reflex disturb- 
ances depends not only upon the amenability of the primary 
exciting cause to treatment, but also upon the duration of the 
affection before the patient comes under observation. The 
persistent excitation of the perceptive centres directly, or in- 
directly through the end organ of the nerve, may effect changes 
which will remain after the exciting cause has been removed. 
Where the case is observed early and depends upon a re- 
movable cause, the results of treatment are, as a rule, favorable. 

Treatment. — Our first object when a case of this character 
presents for treatment is to relieve the aural symptoms from 
which the patient is suffering, without reference to the causa- 
tion. Unless this cause is manifest, much valuable time is 
wasted in searching for the ^etiological feature. The percep- 
tive tract is in a state of constant hyperaesthesia, which from 
its long duration may be difficult to overcome after the excit- 
ing cause has disappeared. Undoubtedly the drug which ex- 
erts the most influence in these cases is bromide of sodium, or 
its equivalent, hydrobromic acid. By the administration of 
these remedies the receptive centres are rendered less sensi- 
tive to the action of stimuli. The effect is similar to that ob- 
tained when a broken limb or strained joint is placed in a 
fixation apparatus ; the nervous tissues are put completely at 
rest, so to speak, by rendering them insensible to the action 
of the stimulus. Our next effort should be to discover the 
cause of the affection ; this can only be done by a thorough 
investigation of the history of the case— not only the history 
of the disease, but one calculated to elicit all facts of medical 
or surgical interest throughout the entire course of the pa- 



672 REFLEX AURAL DISTURBANCES. 

tient's life. An injury received in childhood and entirely for- 
gotten may have set in play forces, which in adult years have 
produced the symptoms complained of. The age of the pa- 
tient is to be borne in mind, particularly in the case of females, 
since the period about the menopause is a time at which these 
symptoms are particularly prone to make their appearance. 
The habit of life, the occupation, and all facts which may 
directlv or indirectly exert an influence upon the nervous 
tone of the body, should be carefully investigated. Several 
factors may present as a possible cause of the aural disturb- 
ance, and time is necessary for the thorough elimination of 
the unimportant ones. It should always be borne in mind 
that these cases are among the most troublesome that we 
have to treat, and may for a long time be irresponsive to all 
our efforts. It is only by the process of exclusion that the 
exact ^etiological feature can be discovered, after which its 
correction is usually a matter of comparative simplicity. 

Diathetic conditions, particularly gout and rheumatism, 
may have manifested themselves previously in no other man- 
ner, and the svmptoms referable to the organ of hearing may 
be the first intimation of the presence of such conditions. The 
history of heredity in such a case is the only clew to guide us 
to the discovery of the cause operative in the production of 
symptoms. 

Where bromides fail to control the reflex phenomena, hy- 
oscyamus, either in the form of the tincture or in the form of 
the alkaloid — hyoscvamine — may serve an efficient purpose. 
Under no circumstances should morphine be administered, 
since it is easy for the patient to acquire the opium habit if 
this practice is once begun. The various antispasmodics, 
such as asafcetida, valerian, galbanum, etc., are of use in cer- 
tain cases, and indications for their administration are usually 
sufficiently clear. Where the symptoms have persisted for a 
long time and there are evidences of vascular dilatation, the 
fluid extract of ergot, in doses of fifteen to twenty minims, 
three times dailv, exerts a beneficial action. 

Symptoms of venous congestion dependent upon imperfect 
cardiac action demand the use of stimulants. Of these, strych- 
nine is probablv the best, provided no organic lesion is pres- 
ent. If the disturbance of circulation is only moderate, the 
use of a certain amount of an alcoholic stimulant daily is a 
valuable means of effecting the desired change. In asthenic 



TREATMENT. 



673 



cases, particularly where the patient has suffered from over- 
work, the addition of a moderate amount of wine to the 
dietary is followed frequently by happy results ; the desired 
stimulating result is thus obtained without resorting to the 
administration of drugs. In cases where anasmia is coinci- 
dent, naturally this condition must be treated on general 
medical principles; and the same is true of the management 
of those cases where there is a plethoric intracranial con- 
dition. 



CHAPTER XLVII. 

DEAF-MUTISM. 

The loss of audition in the early years of life, or the ab- 
sence of this special sense as a congenital defect, invariably 
leads to mutism. It is manifestly difficult to determine in 
many cases whether the power of sound perception has been 
destroyed by some disease in infancy or has been absent 
from birth. Practically the question is one of but little im- 
portance, as each case must present features peculiar .to itself. 

JEtiology. — Heredity seems to play an important part in 
the causation of congenital deaf-mutism. Several members 
of the same family are frequently affected, although direct 
transmission is rather infrequent, the offspring of parents 
afflicted with the malady as a rule escaping. Consanguinity 
of the parents is among the most common of the causes, and 
the greater frequency of deaf-mutism among the inhabitants 
of mountainous districts is probably to be explained by the 
fact that intermarriage is much more common among such 
people. The station of life exerts very little influence upon 
the congenital form of the disease. Defective mental devel- 
opment is not, as a rule, associated with a congenital defect 
in audition, and in many suffering from the loss of this special 
sense the mental faculties seem to be developed beyond the 
normal standard. Hereditary specific disease is a causative 
factor in certain cases. 

Occasionally the affection seems attributable to influences 
during intra-uterine life, such as a severe mental shock to the 
mother, or some physical injury. 

Among the causes which lead to acquired deaf-mutism 
may be mentioned injuries to the head during labor or in 
early infancy ; the acute infectious diseases, leading to involve- 
ment of the perceptive tract, either primarily or as a result 
of a preceding middle-ear inflammation ; acute and chronic 
inflammatory conditions within the cranium ; adenoid vegeta- 

(674) 



PATHOLOGY. 



675 



tions, causing a chronic congestion of the middle ear and 
labyrinth as well, the chronic hyperemia of the middle ear 
leading to repeated attacks of acute catarrhal otitis in infancy. 
The precise manner in which the organ of hearing is affected 
in these diseases has already been dilated upon in the preced- 
ing chapters, and need not be repeated here. It is enough to 
remember that any affection of the conducting or perceiving 
mechanism which is sufficiently extensive to cause profound 
impairment of hearing will lead to deaf-mutism if it occurs 
in the early years of life, before the child has acquired the 
power of articulate speech. Even in children of four years of 
age, who can speak fairly well, the loss of the sense of hearing 
is often followed by mutism, the patients forgetting the few 
words which they have learned. This occurs almost invari- 
ably, unless special attention is directed toward its preven- 
tion. In older children the loss of audition is not necessarily 
followed by mutism. 

Pathology. — The congenital absence of some essential por- 
tion of the conducting mechanism has been found in a num- 
ber of cases which have been investigated post mortem. In 
speaking of deformities of the auricle, mention was made of 
the frequent absence of the bony meatus in those cases, and of 
the almost invariable malformation or absence of the deeper 
portions of the conducting mechanism in cases of congenital 
atresia of the canal. Acquired atresia of the meatus, if occur- 
ring in very early life, might also lead to deaf-mutism. Intra- 
tympanic changes preventing vibration of the labyrinthine 
fluid have also been found in certain instances. Occlusion 
of the round and oval windows, either as a congenital defor- 
mity or as the sequel to a pathological process in early life, 
constitutes the lesion in some cases. 

A congenital defect or an acquired lesion in the labyrinth, 
auditory nerve trunk, or in the nuclei of origin, fibres of com- 
munication, or cortical areas, constitute briefly the anatomical 
characteristics of cases resulting from interference with the 
perceptive mechanism. 

Among the secondary changes may be mentioned the 
lack of development in the vocal organs from prolonged dis- 
use. In cases presenting a lesion of the conducting mechan- 
ism sufficient to account for the absence of audition, it is 
probable that the changes in the perceptive tract may be due 
to the same cause. 



6y6 



DEAF-MUTISM. 



Symptomatology. — In very young children who have 
never spoken, the first symptom noted is usually the failure 
to acquire the power of articulate speech. Attention is then 
directed to the ears, and it is discovered that the auditory 
sense is also wanting. In older children, the failure to re- 
spond when spoken to and the gradual appearance of mutism 
declare the nature of the affection. In these older cases the 
hearing may not be entirely lost at first, and as the patient 
seems to hear loud sounds, parents often neglect the condi- 
tion until it is too late to prevent deaf-mutism. 

Diagnosis. — Since the age at which children acquire the 
power of articulate speech varies greatly, and as the same is 
true of the age at which the infant responds to stimulation of 
the organ of hearing, it is often difficult to determine whether 
or not a child is deaf or whether the development of the 
special sense is delayed simply. With a history of any pre- 
vious intracranial disease or any evidence upon ocular in- 
spection of an abnormity, congenital or acquired, of the organ 
of hearing there is naturally a strong suspicion that the con- 
ditions are interdependent. When the child has learned a few 
words and fails to advance, the diagnosis naturally presents 
no difficulties. It is certainly unsafe to give any other than a. 
guarded prognosis in patients under eighteen months of age. 

Even very young children should be carefully tested as to 
their ability to perceive sounds varying in intensity and pitch. 
Tuning forks of low and high pitch furnish a convenient means 
of determining the probable presence of even a slight amount 
of audition. The forks should be set in vibration and held 
first before the ear, the attention of the child being diverted 
from the movements of the examiner. If the fork is heard, the 
little patient will usually give evidence of the fact, either by 
turning toward the source of sound, or there will be a change 
in facial expression which will be easily recognizable. If there 
is any doubt, the experiment may be repeated and the fork be 
held near the ear without being set in vibration. In the same 
manner bone conduction should be tested, the vibrating fork, 
and the same instrument in a state of rest being brought alter- 
nately in contact with the head. The Galton whistle should 
also be employed, and even in young children it is sometimes 
possible to obtain the limits of audition with fair accuracy. 

Clapping the hands behind the child's head, snapping the 
fingers, etc., are also tests which may be of use ; but my own 



PROGNOSIS— TREATMENT. 677 

experience has been that the tuning fork and Galton whistle 
will furnish the desired information. 

Prognosis. — This is necessarily grave. Politzer* consid- 
ers that the prognosis is better in the congenital than in the 
acquired cases. Certainly in those of congenital origin an 
unfavorable opinion should not be given in very early life, as 
the special senses may develop later. In the cases which 
follow any affection in early infancy, the nature of the disease 
which produced the aural affection, the extent of the local 
process, and the length of time which has elapsed before the 
patient comes under observation, all influence the prognosis. 

Treatment. — When the malady depends upon a known 
cause the indications for treatment will be clear. In all cases 
presenting a condition which could give rise to the profound 
impairment this should be removed. In young children the 
presence of adenoid vegetations should be determined, and if 
the drum membranes are intact any mass of this kind should 
be removed. In the same manner the history of an attack of 
epidemic cerebro-spinal meningitis or of an affection which 
could induce a labyrinthine inflammation should be an indi- 
cation for the use of the proper therapeutic measures. A 
thorough examination should always be made, but if no indi- 
cations are found for any particular plan of treatment, the sur- 
geon should remember that therapeutic measures are useless 
in many cases and that valuable time may be lost. If there is 
no indication for any one plan of treatment, the child should 
at once be placed in the hands of those who make the educa- 
tion of such patients a life study. It is rare in any case which 
comes under observation during childhood to find a com- 
plete absence of the auditory function, and by proper train- 
ing this may be much improved. The best results are ob- 
tained by those methods which stimulate the portion of the 
perceptive tract which remains by the use of the human 
voice, the sound being conveyed to the ear through a proper 
instrument, and by education render it capable of supplying 
the place of the perfect organ of hearing. It is surprising 
how much can be gained if these children come under ob- 
servation at an early period, and when we have decided that 
nothing can be done to relieve the condition it is our duty to 
urge their education in this manner. 

* Diseases of the Ear, American edition, 1894, p. 706. 



DISEASES OF THE XOSE AXD NASO-PHARYNX. 

It is necessary to consider, in connection with the ear, 
certain affections of the upper air passages which either have 
been operative in the production of the aural condition, or 
still exert a marked influence upon it. The principal affec- 
tions under this head will be considered briefly, and more 
with reference to their treatment than to the special symp- 
toms which they produce. 

We may classify affections of the upper air passages which 
come under this head as hypertrophic and atrophic. The 
first condition interferes with the circulation within the tym- 
panum and labyrinth, and also disturbs the equilibrium of 
the drum membrane and ossicles by interfering with the 
free ventilation of the tympanic cavity. Atrophic changes, 
on the other hand, are much less frequently operative in the 
production of aural symptoms. Occasionally they represent 
the results of a previous inflammatory condition which has 
caused the aural affection, but, at the time when the atrophic 
changes are observed, exert but little influence upon the con- 
dition of the ear. The slight effect which they produce is 
mechanical, and depends upon the efforts of the patient in 
relieving the mucous membrane of accumulations of inspis- 
sated secretion dependent upon its atrophied condition. All 
these movements of the pharynx affect the calibre of the 
Eustachian tube and interfere with the atmospheric pressure 
within the tympanum. 

Anatomically we shall consider — 

i. Diseases of the nasal cavity. 

2. Diseases of the naso-pharynx. 

Under diseases of the nasal passages we have belonging 
to the group characterized by the presence of newly formed 
tissue, hypertrophic rhinitis and deformities of the nasal sep- 
tum. An atrophic condition of the mucous membrane lining 
the nasal cavity is more rare, and constitutes the disease 
known as atrophic rhinitis. 

(6 7 S) 



DISEASES OF THE NOSE AND NASO-PHARYNX. 679. 

In the nasopharynx the most common hypertrophic con- 
dition is that known as adenoid vegetations, or enlargement 
of the pharyngeal tonsil. Neoplasms will not be considered 
here, since the aural symptoms to which they give rise are 
always secondary to those referred to the region from which 
the growth springs. An atrophic condition of the nasophar- 
yngeal mucous membrane constitutes the lesion in so-called 
naso-pharyngeal catarrh. 



CHAPTER XLVIII. 

HYPERTROPHIC RHINITIS. — DEFORMITIES OF THE NASAL 

SEPTUM. 

Hypertrophic Rhinitis. 

This condition consists in a true hypertrophy of the ele- 
ments which go to make up the turbinated bodies, and in- 
volves especially the inferior turbinated body. In addition 
to the new growth of connective tissue present, the venous 
sinuses inclosed between its meshes become tortuous, and 
increase in size and in number. As a result of these changes, 
the tissue covering the inferior turbinated bone is increased 
in volume, and in marked cases hangs loosely from its bony 
attachment, so as to obstruct the nostril to a considerable 
degree. When the venous channels are engorged with 
blood, this obstructing mass may attain such a size as to 
completely close the inferior meatus and prevent the passage 
of air. The condition probably depends most frequently, 
according to Bosworth, upon a deformity of the nasal sep- 
tum, and is most marked upon the side which is least ob- 
structed by the septal projection. Owing to the obstruction 
of the opposite nostril, each act of inspiration rarefies the air 
in the opposite nasal chamber and favors dilatation of the 
veins imbedded in the turbinated tissue. Continued for a 
long time, permanent tissue changes take place, resulting in 
the chronic venous engorgement, and in the hypertrophic 
tissue changes above enumerated. Such a condition renders 
the patient extremely susceptible to variations in temperature, 
which result in the affection commonly known as " cold in 
the head." Repeated attacks of this character operate to 
increase the chronic condition which underlies it. Without 
either entering into an enumeration of the various reflex dis- 
turbances depending upon this nasal condition, or dwelling 
upon the various local symptoms which are caused, we may 
state that the most common symptom of which the sufferer 
complains is the inability to breathe through the nose, and of 

(680) 



EFFECT OF OBSTRUCTIVE CONDITIONS. 68 1 

frequently repeated colds in the head. The effect of these 
attacks of nasal stenosis may influence the hearing to a 
marked degree. Patients almost invariably state that during 
such an attack the hearing is much less acute than when the 
nasal respiration is not interfered with, and that, as the at- 
tacks increase in frequency, complete restoration of the hear- 
ing does not take place as readily. The intervals during 
which the hearing is fairly good become shorter and shorter, 
until every fresh attack seems to leave the power of audition 
more impaired. While many of these symptoms depend 
upon interference both with the circulation within the tym- 
panum and the Eustachian tube, and with the proper ventila- 
tion of the middle ear, it is certain that a large proportion of 
cases are met with in which a physical examination reveals 
the Eustachian tube patent throughout the entire attack, and 
in these cases we must conclude that the turgescence of the 
turbinated bodies interferes with the venous return current 
from the labyrinth, causing labyrinthine congestion. Func- 
tional examination of these patients seems to confirm this 
view, and it is therefore important to remember that the 
venous engorgement within the nasal passages is operative 
in the production of labyrinthine symptoms directly, as well 
as in exciting changes in the tympanic cavity. 

This is undoubtedly the reason why, in many cases, sub- 
jective noises will be improved by treating the upper air pas- 
sages, although upon functional examination the patients 
exhibit none of the phenomena characteristic of an involve- 
ment of the conducting mechanism. The symptoms are, 
without doubt, due to vascular changes within the labyrinth 
dependent upon the turgescence of the turbinated tissue 
within the nasal cavity, and a removal of the cause relieves 
the symptoms. This fact certainly broadens the field of use- 
fulness of intranasal surgery, which has quite commonly been 
supposed to be of value only in affections of the middle ear. 
Symptoms referable to the nasal passages themselves have 
already been alluded to, while a more detailed account of the 
various aural symptoms will be found under the different 
diseases before described. 

Concerning the diagnosis of the condition, an examination 
both by anterior and posterior rhinoscopy will render its 
recognition easy. Upon anterior rhinoscopic examination, 
the inferior turbinated body will be seen to project into the 

45 



682 HYPERTROPHIC RHINITIS. 

passage, occluding- it more or less completely and preventing- 
an inspection of the posterior wall of the pharyngeal vault 
through the anterior nares. Where a deformity of the sep- 
tum is present, the hypertrophy will be found more marked 
upon the side opposite to that occluded by the septal obstruc- 
tion. Curiously enough, the patient will complain of this 
nostril as the one obstructed, the reason being that respira- 
tion through the opposite passage having been imperfect for 
a long time, he has ceased to observe changes in its patency,, 
while the obstruction upon the opposite side, or the one upon 
which he depends for nasal respiration, is immediately recog- 
nized, as any increased turgescence practically renders nasal 
respiration impossible. Impact with a probe temporarily ex- 
presses the blood from the swollen turbinated tissue, the 
engorged condition immediately recurring as soon as me- 
chanical pressure is removed. This examination with a 
probe also reveals to the operator that the membrane is 
thickened ; it feels velvety to the touch as the probe presses 
it against the outer bony wall of the nasal cavity. Posterior 
rhinoscopy will reveal a similar condition over the posterior 
extremity of the lower turbinated body, and in some instances 
the hypertrophic changes may be more marked here than an- 
teriorly. The posterior extremity of the inferior turbinated 
body may project into the cavity of the naso-pharynx as a 
round mass, completely occluding the choana of the affected 
side. Occasionally, instead of presenting a smooth contour, 
the surface of the mass is irregularly mammillated. This 
constitutes the so-called posterior hypertrophy, and may be 
present upon both sides. 

The middle turbinated body may present evidences of 
hypertrophy, but less extensive usually than those exhibited 
by the inferior. 

If a ten-per-cent solution of cocaine is sprayed into the 
anterior nares, and the parts again examined after a few min- 
utes, a marked change will be observed. Owing to the ac- 
tion of the drug, the venous engorgement will have disap- 
peared, the mucous membrane will be seen to apply itself 
more closely to the bony parts beneath, and the passage will 
be correspondingly more patent. The posterior pharyngeal 
wall will be readily seen in most instances, if the head of the 
patient is held in such a position that the floor of the nasal 
cavity is horizontal. In order to render this inspection of 



TREATMENT. 683 

the posterior wall possible, the tip of the nose must be tilted 
up strongly, and the operator must so direct the rays of light 
that the deepest portion of the passage will be thoroughly 
illuminated. The light reflex of the posterior pharyngeal 
wall will then be seen, its recognition being more easy if the 
patient is asked to pronounce the letter k, thus elevating the 
soft palate. During this act the levator palati muscle will 
be seen to pass across the field of vision, encroaching upon 
the posterior nasal orifice. 

The results of treatment of this condition are exceedingly 
satisfactory, and it will be always possible not only to relieve 
the attacks of intermittent turgescence of the mucous mem- 
brane, but also to cause the absorption of hyperplastic tissue 
and to return the membrane to its normal condition. Our 
efforts at treatment must be directed both to the results of 
the hyperplastic process and toward the removal of those 
causes which operate to produce the intermittent turgescence 
of the membrane. 

If there is an obstruction upon one side due to a deform- 
ity of the nasal septum, this must first receive attention. 
The particular manner in which this shall be done will de- 
pend upon the choice of the individual operator, and some- 
what upon the character of the obstruction. Where a prom- 
inent ridge is present this is best removed by means of the 
nasal saw. Where the septal obstruction is not sufficiently 
circumscribed to admit of removal in this manner, it may be 
burned away by means of the galvano-cautery. Some prefer 
the use of the electric trephine, and good results undoubt- 
edly follow the use of this instrument, but the author has 
had no personal experience with it. For the relief of the 
turbinate hypertrophy the membrane should first be exsan- 
guinated by means of cocaine, after which a small bead of 
chromic acid melted upon the tip of a metal probe should be 
applied to a limited area over the inferior turbinated body. 
The site of the application should correspond to that which 
was most prominent before cocaine was applied. The super- 
ficial extent of this application will depend upon the degree 
of the previous turgescence ; usually the membrane is cov- 
ered with the chromic acid over an area about the size of a 
split pea. Care should be taken to dry the nasal mucous 
membrane with a pledget of cotton before applying the 
chromic acid ; any excess of acid is to be immediately re- 



684 DEFORMITIES OF THE NASAL SEPTUM. 

moved by means of a dry pledget of cotton, to prevent its 
spreading over the surface of the membrane. The result of 
this application is to form an inelastic eschar, which pre- 
vents the swelling of the turbinated tissue after the effect of 
the cocaine has passed away. The blood vessels are thus 
supported, and their walls resume their normal tone. The 
slough separates at the end of from five to ten days, after 
which the operation is repeated over another portion of the 
turbinated body. These applications are continued until the 
patency of the passage has been restored. When the hyper- 
trophy is excessive the cold wire snare may be used to re- 
move redundant portions. The membrane is first anaesthet- 
ized with cocaine and the loop made to surround the mass. 
The wire is then drawn into the tube and cuts through the 
tissue which it surrounds. When the mass is situated in the 
posterior nares the wire loop should be made to cut through 
slowly by using the screw. In this manner haemorrhage is 
avoided. As cocaine exsanguinates the membrane, it is well 
to use only a sufficient quantity to produce anaesthesia, in 
order that the snare may remove as much of the swollen mu- 
cous membrane as possible. After the operation is completed 
a little iodol is to be insufflated upon the cut surface, and the 
patient directed to avoid forcible efforts at clearing the nos- 
tril for at least twelve hours. In this way haemorrhage is 
avoided, and prompt recovery is the rule. 

Hygienic rules, such as proper attention to underwear, 
the daily use of the cold bath, etc., must not be forgotten in 
the treatment of these cases. 

Deformities of the Nasal Septum. 

As the condition which obstructive lesions of this char- 
acter produce have been discussed sufficiently under hyper- 
trophic rhinitis, we shall consider here only the surgical pro- 
cedures adopted for the relief of the obstruction. Where the 
deformity consists of a prominent ridge extending from the 
anterior portion of the cavity for a considerable distance 
toward the posterior nares, the nasal saw devised by Bos- 
worth seems to be the most simple instrument for relieving 
the condition. The patency of the passage is to be restored 
by sawing off the obstructing ledge either from above down- 
ward or from below upward, according to the special topog- 
raphy of the lesion and the choice of the operator. This 



TREATMENT. 685 

procedure can be carried out under cocaine anaesthesia, and 
is absolutely painless. Care should be taken that all instru- 
ments used at the operation have been previously sterilized 
by boiling in a one-per-cent carbonate-of-soda solution. After 
the operation, a little iodol is insufflated into the passage, so 
as to cover the exposed surface, and recovery is usually un- 
eventful. 

Where the obstruction is of such a shape that the saw 
can not be used the galvano-cautery may be employed. After 
local anaesthesia has been induced by the use of cocaine, the 
flat platinum blade should be applied to the most prominent 
point and the obstruction burned away. The platinum tip 
should be at a bright-red heat, as a temperature below this 
causes pain, while if it is heated to a higher degree the opera- 
tion is likely to be followed by haemorrhage. It is usually 
unwise to attempt the destruction of a large obstructing mass 
at one sitting. A portion of the obstruction should be burned 
away, and the operation repeated at intervals of ten days or 
two weeks until a patent passage is obtained. The wounded 
surface is dressed in the same manner as when the saw is 
used. 



CHAPTER XLIX. 

ATROPHIC RHINITIS. 

When the nasal passages are the seat of an atrophic 
process the mucous membrane covering- the walls of the 
cavity becomes attenuated and applies itself closely to the 
underlying bony structures. Microscopical examination 
teaches us that this atrophy affects the glands with which 
the membrane is supplied. The secretion is altered in char- 
acter, and contains an excess of solid elements. The result 
is that it dries within the passage forming large irregular 
crusts upon the mucous membrane. As these crusts become 
dry they shrink, expelling the blood from the underlying 
mucosa, and mechanically augment the atrophic changes. 
Bosworth is undoubtedly correct in the statement that the 
disease is of long duration and develops as the result of puru- 
lent rhinitis in childhood, usually after one of the exanthe- 
mata. An examination shows an abnormal patency of the 
nasal passages, the membrane applying itself so closely to 
the bony framework that the turbinated bodies appear 
merely as lines upon the outer walls of the chambers. The 
post-pharyngeal wall can be easily recognized upon anterior 
rhinoscopic examination. Owing to the absence of the nor- 
mal turbinated tissue, the air which reaches the vault of the 
pharynx through the nasal cavity is not properly moistened 
and abstracts moisture from the membrane in this region ; 
the result is that we usually find a mass of inspissated mucus 
lining the vault of the pharynx. The patient complains not 
only of the crusts which are expelled from the nasal cavity, 
but also of the formation of a broad scale of tenacious mucus 
which is drawn down from the vault of the pharynx after 
repeated efforts at clearing the passage. These masses of 
inspissated secretion within the nasal chambers undergo de- 
composition and impart to the breath an extremely fetid odor, 
which is a characteristic feature of the affection. 

The aural symptoms which are present in these cases are 

(686) 



PROGNOSIS— TREATMENT. 687 

ordinarily insignificant, and are usually due to a previous in- 
volvement of the middle ear in childhood, when the purulent 
rhinitis was at its height. It is possible that the imperfect 
moistening of the air may play a part in the production of 
certain aural symptoms, although this has never seemed to 
me probable. It is more likely that the condition within the 
middle ear is concomitant with rather than secondary to the 
nasal condition. 

The treatment of this affection is unsatisfactory as far as 
effecting a permanent cure, but efficient in relieving the pa- 
tient from the disagreeable symptoms which it causes. The 
first measure is to thoroughly cleanse the nasal cavity, remov- 
ing all decomposing crusts. This is best done by the use of 
the nasal douche. At least a quart of a weak saline solution, 
as hot as- can be borne, is to be passed through the nasal 
chambers twice daily ; this not only washes away decompos- 
ing masses, but exercises a certain stimulating action upon 
the membranes. During the day the nasal chambers may be 
cleansed at frequent intervals with an alkaline spray such as 
the following: 

9 Sod. bicarb gr. xx ; 

Acid, boric 3 ss. ; 

Acid, carbolic Til. iv ; 

Glycerin 5 j ; 

Aqua q. s. ad § viij. 

M. Sig. : Dilute with an equal volume of water, and use 
in an atomizer as a nasal spray. 

Later, irrigation may be employed but once daily. If 
faithfully continued, this treatment will prevent the discom- 
fort attendant upon the nasal affection. The use of the nasal 
douche in these cases seldom produces aural symptoms, as 
the nasal passages are free and there is but little danger of 
the fluid entering the tympanum. It should always be re- 
membered in employing the douche that the current should 
enter by the occluded nostril if there is any difference in the 
patency of the two sides. In this way it is practically impos- 
sible for any accident to happen. The relief of the nasal con- 
dition exerts but little influence upon the aural disease. The 
chief source of relief is probably due to the fact that the 
patient makes less vigorous efforts at expelling the crusts by 
blowing the nose, and the sudden increase of tympanic pres- 



688 ATROPHIC RHINITIS. 

sure is thus avoided. In some instances it is wise to fur- 
ther stimulate the parts by the insufflation of the following 
powder immediately after the douche has been used : 

Ijfc Pulv. sanguinariae 3 ss. ; 

Pulv. lycopodii - . . q. s. ad J j. 

This causes considerable pain when insufflated into the nasal 
chambers and produces a profuse watery discharge. In this 
manner the turbinated tissues are stimulated to activity and 
return to a more nearly normal condition. The insufflation 
of the powder is to be discontinued after the tendency to 
crust formation has been checked. 



CHAPTER L. 

ADENOID VEGETATIONS. 

This condition is undoubtedly responsible for more than 
half of the pathological lesions met with in the tympanum. 
It is essentially a disease of childhood, probably a manifesta- 
tion of a constitutional diathesis not inappropriately termed 
by Bosworth " lymphatism." The manner in which a mass 
of lymphatic tissue in the pharyngeal vault influences the 
organ of hearing has already been described in the beginning 
of this section, and need not be repeated. We should bear 
in mind that its influence is not alone confined to the middle 
ear, but that the vessels of the labyrinth undoubtedly suffer 
when this lymphatic tissue is the seat of repeated attacks of 
acute inflammation. 

The symptoms dependent upon the presence of the growth 
are those of nasal obstruction, the sufferer breathing almost 
entirely through the mouth, especially during sleep. The na- 
sal quality of the voice is wanting, and among young children 
there is a persistent discharge from the anterior nares. Such 
a growth becomes easily congested, and the cases present 
with the history of frequent colds in the head. A cold in the 
head in a child under twelve years of age is almost invariably 
dependent upon adenoid vegetations within the pharyngeal 
vault. 

The aural symptoms are quite as characteristic as those 
referable to the air passages. There are frequent attacks of 
earache, terminating in some cases in a discharge from the 
ear, which may continue as a purulent otitis media ; or where 
the inflammation is less severe there may be repeated attacks 
of tubo-tympanic congestion or of acute catarrhal otitis media 
without rupture of the drum membrane. In some instances 
the membrane is the seat of a minute rupture, and there is the 
history of slight serous discharge immediately following the 
attack, but disappearing spontaneously at the end of a few 
days. 

(68 9 ) 



690 



ADENOID VEGETATIONS. 



The disturbances of function are also intermittent in char- 
acter. With every cold in the head the hearing becomes 
dull, and, if the patient is old enough to explain the symp- 
toms, he complains of a full or stuffy feeling in the ears, in 
addition to the impaired hearing. Many times this last symp- 
tom is misinterpreted in young subjects, and the child is con- 
sidered inattentive. Such a history should always lead to a 
careful examination of the ears, as most children who seem 
to be " absent-minded " are really hard of hearing. 

An examination of the oro-pharynx frequently shows that 
the faucial tonsils are enlarged, although they may be normal 
in size. Enlarged lymphatic nodules are frequently seen ir- 
regularly distributed upon the posterior pharyngeal wall, and 
are most numerous in the region of the posterior folds. Upon 
posterior rhinoscopy, the vault of the pharynx is seen to be 
occupied by a mass attached either to the roof or springing 
from the posterior wall. This mass may be most prominent 
in the median line, or the membrane covering the pharyngeal 
vault may be uniformly thickened, excepting in the region 
about the Eustachian orifices, where it is thrown into numer- 
ous folds and reduplications. The membrane covering the 
entire naso-pharyngeal space appears velvety and soft, resem- 
bling somewhat the faucial tonsils in appearance, although the 
tissue appears less firm. Where posterior rhinoscopy can 
not be conducted satisfactorily, such a growth may be seen 
by anterior rhinoscopy if the turbinated bodies have been 
previously exsanguinated by the application of a solution of 
cocaine. When this method is employed, the patient should 
sit so that the floor of the nasal chambers is very nearly in 
the horizontal plane. If the light is directed into the cavity, 
the adenoid growth will be seen lying behind the posterior na- 
sal opening, and sometimes encroaching upon it, if it springs 
from the roof of the naso-pharynx. When attached to the 
posterior wall, it is recognized by the undue prominence of 
this region, while manipulation with a probe demonstrates its 
papillary character. 

In very young children either of these methods of exami- 
nation may be impossible. In such a case the mouth should 
be held open either with a mouth gag or by means of a cork 
inserted between the teeth, and the surgeon should pass the 
index finger behind the palate into the naso-pharynx ; the 
presence of the adenoid vegetations will be recognized by 



OPERATIVE TREATMENT. 



691 



the soft, velvety feeling of the membrane. Upon withdraw- 
ing the finger it will be usually found covered with blood, as 
in young children the soft tissue is easily wounded. 

The removal of such a mass is the only treatment to be 
considered if aural symptoms are present. The author's 
preference is the performance of a. complete operation under 
general anaesthesia, the growth being removed by the forceps 
and curette. 

All instruments are to be sterilized by boiling. The child 
is placed upon the table in a recumbent position. For chil- 
dren under twelve years of age chloroform is without 
doubt the best anaesthetic to employ. After complete an- 
aesthesia the head is thrown backward over the edge of the 
table, or the same end can be attained by placing a small, 
hard pillow under the neck. By this procedure the vault of 
the pharynx is made to occupy a lower level than the larynx, 
and the danger of the accidental entrance of blood into the 
trachea is reduced to a minimum. The jaws are held apart 
by a properly constructed mouth gag, and the surgeon, stand- 
ing upon the right of the patient, introduces the left fore- 
finger behind the palate, where it remains until the operation 
is completed. The closed forceps held in the right hand is 
now passed along the left forefinger as a guide into the naso- 
pharynx, where it is opened and made to grasp as much 
of the growth as possible, the manipulation being directed 
by the left index finger. In this way the growth is removed 
piecemeal, and the operation is not considered complete until 
the examining finger fails to discover any masses projecting 
into the naso-pharyngeal space. The operation is completed 
by passing the curette into the space and sweeping it along 
each lateral wall and along the posterior wall of the cavity. 
The child is then turned over on the face, to facilitate the dis- 
charge of blood which has accumulated in the naso-pharynx 
during the progress of the operation, the mouth gag not be- 
ing removed until this position has been assumed. No after- 
treatment is necessary, and, if the instruments have been 
sterilized, recovery is uneventful. In rare cases the operation 
is followed by an acute congestion within the tympanum or 
by a catarrhal inflammation. This accident happens so sel- 
dom that it can be practically disregarded. Another com- 
plication which is perhaps more frequent is an acute follicular 
tonsillitis, but this is also very rare. 



692 ADENOID VEGETATIONS. 

Intimately associated with enlargement of the pharyngeal 
tonsil is a similar condition affecting the lymphatic tissue 
of the oro-pharynx. Many years ago the removal of en- 
larged faucial tonsils for the relief of impaired hearing was 
advocated by Yearsley. After Meyer had shown the marked 
effect which hypertrophy of the pharyngeal tonsil exerted in 
the causation of inflammatory processes within the tympanum, 
removal of the faucial tonsils for these conditions fell into dis- 
use. It is probable that excision of the faucial tonsils is de- 
manded in many cases of aural disease both of the suppura- 
tive and of the nonsuppurative variety. It is also probable 
that the beneficial effect produced is due largely to the ab- 
sorption of the pharyngeal tonsil which follows the operation 
in many cases. As a rule, however, whenever the faucial 
tonsils are hypertrophied, and at the same time an inflam- 
matory process is present within the tympanum, their re- 
moval should be advocated. In the large majority of cases 
enlarged faucial tonsils occur coincidently with an enlarged 
pharyngeal tonsil, and should be removed at the same time 
that the operation is performed upon the adenoid vegetations. 

In subjects under the age of twelve, tonsillotomy is best 
performed by any one of the various instruments which have 
been devised for this purpose. The author prefers Mathieu's 
instrument, but any of the others are probably equally efficient 
in expert hands. 

When tonsillotomy and the removal of adenoid vegeta- 
tions are practiced at the same operation, it is usually wise to 
remove the faucial tonsils first, as the haemorrhage from the 
pharyngeal vault rather obscures the field of operation if the 
adenoid growth is first attacked. 



CHAPTER LI. 

NASO-PHARYNGEAL CATARRH. 

This condition is probably due to atrophic changes which 
take place in the pharyngeal tonsil in adult life. These 
cnanges consist in the disappearance of the cellular elements 
of the lymphatic nodules, and an increase in the fibrous tissue 
constituting the framework of the gland. It is probable that 
if the complete history of every case could be obtained we 
should find that these patients suffered from symptoms refer- 
able to a moderate hypertrophy of the pharyngeal tonsil dur- 
ing childhood. The condition, however, was not sufficiently 
marked to demand surgical interference, and in early adult 
life the symptoms disappeared. It is only late in life, when 
sclerotic changes take place, that symptoms dependent upon 
the presence of this tissue again appear. The prominent 
symptom of which these patients complain is the accumula- 
tion of viscid secretion in the pharyngeal vault. This secre- 
tion excites repeated efforts upon the part of the patient to 
draw the mass back into the mouth and expel it in this way. 
The annoyance which the condition occasions varies greatly 
in different individuals. In some, the effort to expel the in- 
spissated mucus may bring on an attack of retching, or even 
vomiting, while in other instances spasmodic attacks of cough- 
ing may be excited. All manifestations due to the presence 
of the mass are exaggerated when the patient suffers from a 
cold in the head, and each fresh attack of inflammation ren- 
ders the victim more liable to a succeeding attack upon slight 
exposure. 

The aural symptoms in general are those enumerated in 
the chapter upon Chronic Catarrhal Otitis Media. We may 
find either a hyperplastic or a hypertrophic process within 
the middle ear. It is a question to what extent the naso- 
pharyngeal condition has been productive of the aural lesion. 
My own belief is that the two processes are coexistent rather 
than interdependent, and that the middle-ear changes have 

(693) 



694 NASO-PHARYNGEAL CATARRH. 

resulted from the presence of an excessive amount of adenoid 
tissue in the pharyngeal vault at an early period of life, and 
do not depend upon the sclerotic changes which have subse- 
quently taken place in this tissue, although they are similar in 
character. Naturally the aural symptoms are aggravated by 
the congestion of the naso-pharyngeal mucous membrane, on 
account of the intimate relation which exists between the 
vessels in the two regions ; but it is unwarrantable to assume 
that any treatment directed toward a correction of the naso- 
pharyngeal lesion will do more than exempt the organ of 
hearing from repeated attacks of congestion. The sclerotic 
changes have advanced to such an extent in these cases that 
we can not hope for an absorption of the new tissue, even if 
the parts are kept in a state of perfect equilibrium. Efforts 
at treatment will cut short an attack of inflammation in this 
region and relieve the throat symptoms, and will at the same 
time relieve the acute aural symptoms and cause the tym- 
panic mucous membrane to return to the condition present 
before the acute attack. Beyond this, however, no treatment 
of the naso-pharynx will be of avail in adult life. 

The treatment of the condition consists in local applica- 
tions of an astringent solution to the naso-pharyngeal mucous 
membrane. These applications may be made by means of a 
curved applicator carried behind the soft palate, or, as I pre- 
fer, by a cotton-tipped probe carried through the anterior 
nares, the nasal mucous membrane having been previously 
anaesthetized with cocaine. The strength of the application 
should vary with the intensity of the inflammation. In the 
early stages a solution of nitrate of silver, thirty grains to 
the ounce, thoroughly applied to the naso-pharynx, may stop 
the progress of the attack completely. In the later stages a 
weaker solution should be employed. For the chronic con- 
dition relief is obtained by cleansing the naso-pharyngeal mu- 
cous membrane either by the post-nasal syringe or by means 
of a spray through the anterior nares ; after which the appli- 
cation of a solution of nitrate of silver, of a strength of from 
ten to fifteen grains to the ounce, applied in the manner 
already described, will frequently be of service in relieving 
the discomfort attendant upon the condition. 



CHAPTER LII. 

ARTIFICIAL AIDS TO HEARING. 

In certain cases of impaired hearing of long standing, local 
treatment must be entirely futile. The impairment of function 
is so great as to render the improvement at the hands of the 
otologist absolutely impossible. These cases are found chiefly 
among individuals in advanced life where senile changes have 
taken place, both in the middle ear and in the perceptive 
mechanism. It is necessary, therefore, for the patient to call 
to his aid some device which will collect a larger volume of 
sound waves in order that the transmitting mechanism may be 
set in vibration, and thus permit of a more perfect perception 
of sound. 

While the number of instruments which have been devised 
for this purpose is numerous, all depend essentially upon the 
simple principle of collecting a larger number of sound vibra- 
tions for transmission to the deeper parts. The simplest instru- 
ment, and the one which embodies the principle of all others, is 
the ordinary ear-trumpet. This is essentially a funnel, the small- 
er end of which is placed in the ear, while the broad end is turned 
toward the source of sound. In this way the sound waves are 
collected and reflected into the meatus, where they impinge 
upon the transmitting mechanism and are conducted to the 
deeper parts. Many modifications of this simple instrument 
have been made. Instead of a simple funnel, the sound-collecter 
has been changed in form so as to fit closely to the surface of 
the skull behind the ear, the sound-collector terminating in 
a small tube which fits into the external auditory meatus. 
While an appliance of this kind is sometimes of use to the 
patient, its appearance attracts attention, and it offers practically 
no advantage over the more simple ear-trumpet. 

Of the ear-trumpets in use, perhaps the best is the small 
London hearing horn, the receiver of which is a bell-shaped 
shell of some light metal. From the side of this shell a small 

(695) 



6 9 6 



ARTIFICIAL AIDS TO HEARING. 



tube projects which is bent at right angles to the axis of the 
bell and is fitted with an ear tip for insertion into the external 
auditory meatus. The instrument is quite easily held in the 
hollow of the hand, and by placing the hand holding the instru- 
ment to the ear, with the ear tip in position in the canal, a con- 
siderably increased volume of sound is received. Up to the 
present time all attempts to magnify sound, so to speak, by 
means of some device which could be inserted into the external 
auditory canal, which would be practically invisible, have met 
with no success. The principle of the ear-trumpet already 
described in the above devices, has been applied to various arti- 
cles of common use; for instance, the handle of an ordinary 
walking-stick may be fashioned into the form of an ear-trumpet, 
so as to collect the sonorous vibrations by simply holding the 
cane in the hand so that the ear tip is inserted into the canal 
and an increased number of sound waves thus collected and 
transmitted. 

In another device the collecting cone is somewhat flattened 
and its external surface corrugated, so as to represent roughly 
a fan, the handle of the fan containing the tube for insertion 
into the ear; the fan being held in the hand, the ear tip is 
placed in the canal and the instrument effects its purpose. 

A rather clever device has been invented by Vallerie, in 
which the hearing horn takes the form of the handle of a lorg- 
nette. This instrument perhaps attracts less attention than the 
other devices. 

Quite recently an instrument has been devised acting upon 
the principle of the telephone. In this instrument a small tele- 
phonic receiver is held close to the ear. This is connected by 
flexible cords with a sound receiver which may be worn beneath 
the coat or beneath the folds of the dress, while a small storage 
battery is carried in the pocket. A modified and more bulky 
form of this apparatus has been devised in which the sound 
receiver is placed upon a desk or table. This instrument cer- 
tainly helps some patients, and they are able to carry on a con- 
versation, listen to lectures and music, or enjoy the theatre, 
public speeches, and so forth. At best, however, the device is 
cumbersome and possesses no very great advantages over the 
more simple instruments already detailed. 



INDEX 



Abortive treatment of mastoiditis, 

459- 
author's statistics of, 461. 
Abscess of auricle, 201. 

cerebellar, 476, 586. See Cere- 
bellar Abscess, 476. 
surgical treatment in, 586. 
cerebral, 472, 586. See Cerebral 
Abscess, 472. 
surgical treatment in, 586. 
epidural, 583. 

extradural 471. See Extradural 
Abscess, 471. 
Accidents from mastoid operation, 

536, 538, 540. 
Acoumeter, electric, 146. 

Politzer's, 143. 
Acoustic papilla, 41. 
Acute infectious diseases, aural com- 
plications in, 651. 
involvement of internal ear in, 634. 
involvement of perceptive mechan- 
ism in, 634. See Perceptive 
Mechanism, Involvement of, 
in Acute Infectious Dis- 
eases, 634. 
inflammation of labyrinth, second- 
ary to acute purulent otitis 
media, 629. See Labyrinth, 
Acute Inflammation of, 
Secondary to Acute Puru- 
lent Otitis Media, 629. 
Adenoid growths, effect upon middle 
ear, 133. 
effect upon labyrinth, 134. 
importance of recognition in early 

life. 134. 
vegetations, 689. 
treatment of, 691. 
Adhesions in middle ear, physical 
signs of, 102. 
intratympanic, evidence of, 95. 
within the tympanum, division of, 
496. 



Aids to hearing, artificial, 695. 
Ampullae, 35, 40. 
Anaemia of labyrinth, 601. 
Anaesthesia in middle-ear operations, 

485. See Nitrous Oxide. 
Anastomosis between tubal veins and 

turbinated plexus, 30. 
Anatomy of the ear, 3. 

of the mastoid process, 442. 
Angioma of the auricle, 209. 
Annulus tympanicus, the, 8. 
Anomalies in position of lateral 
sinus, 445. 

of antihelix, 174. 

of antitragus, 175. 

of helix, 174. 

of lobule, 174. 

of tragus, 175. 
Anterior fold, the, 22. 

ligament of malleus, 18. 
division of, 495. 

pyramid, the, 27. 

wall of the tympanum, 13. 
Antihelix, the, 5. 

anomalies of, 174. 

crura of, 5. 

fossa of, 5. 
Antitragus, the, 5. 

anomalies of, 175. 
Anton, 206. 
Antrum, the mastoid, 9, 442, 443. 

position of, 443, 448. 
Appendages, auricular, 178, 179. 
Aquaeductus cochleae, 36. 

Fallopii, 12. 

vestibuli, 35. 
Arch of Corti, 41. 
Arteries of the ear, 28. 

of the labyrinth, 44. 
Artery, ascending pharyngeal, 30. 

anricularis profunda, 30. 

cochlear, 45. 

deep auricular, 30. 

descending palatine. 30. 



46 



(697) 



698 



INDEX 



Artery, facial. 30. 

internal auditory. 44. 45. 
internal carotid. 13. 30. 
internal maxillary. 29. 
occipital. 29. 
posterior auricular. 29. 
pterygo-palatine. 30. 
superficial petrosal. 29. 
temporal, 29. 
tympanic. 29. 
vestibular. 45. 
vestibulo-cochlear. 45. 
Vidian, 30. 
Articulation, incudo-stapedial. 17. 498. 
malleo-incudal. 17. 
stapedio-vestibular. 17. 
Artificial aids to hearing. 695. 
ear-trumpet, 695. 

modifications of. 696. 
telephone. 696. 
Ascending pharyngeal artery. 30. 
Aspergillus of meatus. 246. 247. 
Asymmetry of the ear. 173. 
Atheroma of the auricle. 207. 
Atrophic rhinitis. 686. 

signs of, 136. 
Attolens aurem. 2j. 
Attrahens aurem. z~ . 
Audition, effect of functional nervous 
diseases upon. 662. 
limits of. 148. 
Auditory apparatus, concerted ac- 
tion of. 66. 
cortical centre of. 46. 
Auditory hairs, the, 39. 
hyperesthesia, 71. 
nerve. 45. 

fatigue of. 70. 164. 
galvanic reaction of. 167. 

method of determining. 168. 
increased irritabilitty of. to gal- 
vanic current. 160. 
loss of function of. from disease. 

161. 
reaction of, after destruction of 

labyrinth. 65. 
reaction of. to sonorous vibra- 
tions. 65. 
torpidity of. 626. 
trunk, effect of lesions of. on per- 
ception of musical tones, 165. 
paresthesia. 71. 
process, the. 8. 
Aural affections dependent upon 
chronic visceral conditions, 
654. 



Aural complications in acute infec- 
tious disease. 651. 

in diabetes. 659. 
discharges, bacteria in, 328. 
disturbances, reflex. 668. 
fistula, congenital. 179. 
involvement in gout and rheuma- 
tism, 659. 

in hysteria. 665. 

in leucaemia. 657. 

in metastasis. 655. 

in nephritis. 654. 

in neurasthenia. 662. 

in syphilis. 195. 613: 

in tuberculosis. 656. 
polypi. 404. 

removal of. 416. 417. 
reflexes. 67. 
specula. 83. 

speculum, improvised. 85. 
suppuration, surgical treatment of, 
569- 

intracranial complications of, 
569- 
synergy. 66. 
Auricle, the. 4. 
abscess of. 201. 
angioma of. 209. 
atheroma of. 207. 
benign tumors of. 206. 
contusion of, 183. 
cutaneous diseases of. 187. 
cystoma of. 210. 

treatment of. 211. 
deformities of. 174. 
diseases of. 173. 
eczema of. 187. 

treatment of, 181. 
epithelioma of. 213. 
erysipelas of. 201. 
fibroma of. 206. 
function of. 50. 
gangrene of, 205. 
glands of. 2^. 
hematoma of. 184. 202. 

treatment of. 203. 
herpes of. 193. 

treatment of. 194. 
inflammatory affections of. 200.. . 
intertrigo of. 187. 
lipoma of. 207. 
lupus of. 197. 198. 
malformations of. 173. 176. 
malignant tumors of. 213. 
malposition of, 176. 
ossification of, 204. 



INDEX. 



Auricle, papilloma of, 212. 

pemphigus of, 193. 

perichondritis of, 184, 200. 
treatment of, 185, 201. 

sarcoma of, 216. 

syphilis of, 195. 

wounds of, 183. 
treatment of, 184. 
Auricular appendages, 178. 

artery, the posterior, 29. 
Auricularis magnus nerve, the, 31. 

profunda artery, the, 30. 
Auriculotemporal nerve, the, 31. 
Auscultation, the value of, 103. 
Auscultatory sounds, 113. 

Bacon's scarificator, 227. 
Bacteriological infection of tympan- 
um, culture of discharge in, 302. 

in intratympanic inflammation, 300, 
301. 
Baginsky, 59. 

Ballance, 547, 554, 559, 560, 575. 
Baratoux, 196. 
Barth, 145, 178. 
Basilar membrane, epithelium of, 41. 

function of, 59. 
Bergmann, 474, 546, 547. 
Berthold, 44. 
Bezold, 62, 150, 157. 
Binder, 175. 
Bing, 162. 

Blake, 26, 100, 144, 419. 
Blake's middle-ear syringe, 339. 
Blood supply of the ear, 28. 
Boenninghaus, 580. 
Boettecher, 44. 

Bone conduction, augmentation of, 
by increased labyrinthine pres- 
sure, 161. 

cause of augmentation of, 160. 

estimation of, 151. 

value of, 150, 151. 
Bony canal, the, 7, 9, 11. 
Bosworth, 135, 680, 684, 686, 689. 
Botey, 100. 

Bougie, electric, for dilatation of 
Eustachian tube, 372. 

Eustachian, 313, 389. 
Boyer, 120. 
Brenner, 167. 
Brown, Gardiner, 154. 
Brown-Sequard, 202. 
B runner, 202. 
Bryant, 26. 
Buck, 109, 212, 362. 



Biirkner, 180. 
Burnett, 180. 

Calcific deposits in drum membrane, 

385. 
Canal, the bony, 7. 
the carotid, 13. 
the cartilaginous, 6. 
the cochlear, 36. 
the Eustachian, 13. 
the external auditory, foreign bod- 
ies in, 279. See Meatus, Ex- 
ternal Auditory, Foreign 
Bodies in, 279. 
the Fallopian, 12, 524. 
Canalis centralis modioli, 36. 
reuniens Hensenii, 27- 
spiralis modioli, 36. 
Canals, the semicircular, 35. 

function of, 60. 
Capsule, labyrinthine, rarefying os- 
teitis of, in otosclerosis, 382. 
Caries of the incus in middle-ear 

suppuration, 523. 
Carotid canal, the, 13. 
Cartilaginous meatus, the, 6. 
Cassebohm, 362. 

Catarrh, Eustachian, 304. See Eu- 
stachian Tube,' Congestion 
of, 304. 
naso-pharyngeal, 693. 
tubo-tympanic, 317. See Tubo- 
tympanic Congestion, 317. 
Catarrhal inflammation of the mid- 
dle ear, acute, 327. See Otitis 
Media, Acute Catarrhal, 

327- 
Catheter, bougie, author's, for Eu- 
stachian tube, 313. 
Eustachian, form of, 107. 
Noyes' Eustachian, 124. 
Pomeroy's faucial, 125. 
Catheterization, apparatus for, 109. 
dangers of, 129. 
methods of, 119-121. 
obstacles to. 122. 
of Eustachian tube. 107. 
technique of, in. 
through opposite nostril. 123. 
use of cocaine in. 128. 
value of, as compared with Po- 
litzerization, 130. 
Caudate process, 5. 
Cavity, the tympanic. 12. 
Cerebellar abscess. 476, 586. 
diagnosis of. 477. 



roo 



INDEX. 



Cerebellar abscess, frequency of. 476. 
pathological changes in, 476. 
prognosis of. 477- 

statistics of recoveries. 47S. 
surgery of. 586. 

exploration for. 593. 

site of. 593. 
exposure of cerebellum. 593. 
puncture of cerebellum. 593. 
after-treatment. 594. 
symptomatology. 476. 
increased intracranial pressure. 

476. 
temperature. 476. 477. 
treatment. 478. 593. 
Cerebral abscess. 472. 586. 
diagnosis of. 474. 5 V 
pathology of. 473. 
prognosis of. 475. 
statistics. 475. 
surgery of, 586. 
accidents in. 592. 
after-treatment. 590. 
encephaloscope in. 5S9. 
exploratory procedures in. 587. 
irrigation in. 589. 
technique of. 587. 
symptomatology of. 473. 
treatment of. 475. 586. 
usual site. ?&y. 
Cerumen, impacted. 267. 
aetiology of, 267. 
diagnosis of. 271. 
dilatation of canal from. 268. 
pathology of. 268. 
prognosis of. 272. 
symptomatology of. 269. 
retiex disturbances from. 270. 
vertigo from. 271. 
treatment ot. 274. 
Chatelher. 193. 
Chimani. 209. 
Cholesteatoma. 401. 
acute symptoms following. 402. 
development of. 435. 
Cholewa. 69. 231. 377. 493. 
Chorda tympani nerve, the. 32. 
Chronic catarrhal otitis media. 357. 
See Otitis Media. Chronic 
Catarrhal. 357. 
naso-pharyngitis. 693. 
otorrhcea. radical operation for. 546. 

use of powders in. 414. 
purulent otitis media. 397. See 
Otitis Media. Chronic 
Purulent. 397. 



Chronic purulent otitis media, cere- 
bral abscess in. 472. 
extradural abscess in. 471. 
Circulatory phenomena, 68. 
Cisterna lymphatica. 38. 
Classification of middle-ear opera- 
tions. 485. 
Cleveland. 68. 

Cocaine, use of. in catheterization. 
128. 
in middle-ear operations. 128. 485. 
Cochlea, the. 12. 35. 
function of. ^7. 
result of destruction of, 66. 
the membranous. 40. 
Cochlear artery, the. 45. 
canal, the. 35. 36. 
nerve, the. 45. 

decussation of. 45. 
termination of. 43. 
Coil. Leiter. 460. 
Color of membrana tympani. 92. 
Complicating aural disease. 651. 
Concerted action of auditory appa- 
ratus. 66. 
Concha, the. 5. 
Concussion of labyrinth. 72. 
Conducting apparatus, the. 4. 
mechanism, signs of lesions in. 

154- 

Congenital malformations of the au- 
ricle. 173. 

Congestion, tubal. 304. See Eu- 
stachian Tube. Congestion 

OF. 304. 

tubo-tympanic. 317. See Tubo- 
tympanic Congestion. 317. 
Contusion of the auricle. 183. 
Corradi. 66. 
Corti, arch of. 41. 

membrane of. 43. 

rods of. 58. 
function of. 59. 
Cortical auditory centre, the. 46. 
Cough, reflex aural. 270. 
Cranial fossa, middle. 446. 
Crista vestibuli. 3S- 
Crista? acusticse. 40. 
Croupous external otitis, 261. 
Crura furcata. the. 5. 

helicis. the. 5. 
Culture of discharge in bacterio- 
logical infection of the tympa- 
num. 302. 
Cunningham. 460. 
Cupola, the. 36. 



INDEX. 



;oi 



Cutaneous diseases of the auricle, 

187. 
Cutogno, 38. 

Cystoma of the auricle, 210. 
treatment of, 210. 

Darwinian ear, the, 174. 
Deaf-mutism, aetiology of, 674. 

diagnosis of, 676. 

pathology of, 675. 

prognosis of, 677. 

symptomatology of, 676. 

treatment of, 677. 
Decussation of auditory nerve fibres, 

47- 

Deep auricular artery, the, 30. 

Deformities of the nasal septum, 
684. 

Deiters' cells, 42. 

Deleau, 123. 

Delstanche's masseur, 389. 

Dental caries, effect of, on ear, 69. 

De Rossi, 189. 

Descending palatine artery, the, 30. 

Development of bony meatus, the, 7. 
of tympanic vault, the, 9. 

Diabetes, aural complications in, 659. 

Differential diagnosis, value of func- 
tional examination in, 155. 

Digital examination of pharyngeal 
vault, 133. 

Dilatation of Eustachian tube by 
electric bougie, 372. 

Diphtheria, involvement of internal 
ear in, 637. 

Diphtheritic external otitis, 261. 

Diploic mastoid, 443. 

Disarticulation of incudo-stapedial 
joint, 498, 504. 

Discharges, aural, bacteria in, 328. 

Discharge in bacteriological infec- 
tion of tympanum, culture of, 
302. 

Diseases of the auricle, 173. 
of the external canal, 217. 
of the mastoid, 449. 
of the middle ear, 297. 
of the nose and naso-pharynx, 678. 
of the perceptive mechanism, 597. 
of the mastoid process, 442. 

Division of adhesions within the 
tympanum, 496. 
of the anterior ligament of the 
malleum, 495. 

Drugs, toxic effects of, upon the ear, 
660. 



Drum membrane, the, 21. 

calcific deposits in, 385. 

multiple incision of, 491. 

normal appearance of, 92. 

reproduction of, after removal, 513. 
Ductus endolymphaticus, 38. 
Duel, 372. 

electrolytic method of dilatation, 
372. 
Duration of sound perception as 
quantitative test, 145. 

Ear, anatomy of, 3. 
arteries of, 28. 
asymmetry of, 173. 
blood supply of, 28. 
Darwinian, 174. 
effect of hysteria upon, 665. 

of neurasthenia upon, 662. 

of functional nervous diseases 
upon, 662. 
functional examination of, 142. 
internal, 34. 

involvement of, in acute infectious 
diseases, 651. 

in diabetes, 659. 

in gout and rheumatism, 659. 

in leucaemia, 657. 

in nephritis, 654. 

in syphilis, 613. 

in tuberculosis, 656. 
lymphatics of, 31. 
metastasis of, 655. 
muscles of, 26. 
nerves of, 31. 

physical examination of, 73. 
physiology of, 48. 
" prize-fighters," 184. 
reflex affections of, 668. 
sympathetic involvement of, 621. 
syringe, 234. 

the influence of drugs upon, 660. 
the satyr, 17. 
tone limits of, 48. 
veins of, 34. 
Earache, causes of, 217, 2>33^ 34 1 - 

treatment of, 226, 336. 
Ear-trumpet, 695. 
fan, 696. 

London hearing horn, 695. 
lorgnette, 696. 
walking-stick, 696. 
Eczema of the auricle. 187. 
necrosis of auricle following. 189. 
treatment of, 188. 
Eichler, 44. 



702 



INDEX. 



Eitelberg. 164. 169. 
Electric acoumeter, 145. 
bougie for dilatation of Eustachian 
tube, 372. 
Embolism, labyrinthine, 611. See 
Labyrinthine Embolism, 
611. 
Emphysema, following catheteriza- 
tion, 129. 
Encephaloscope, the, 589, 590. 
Epidemic cerebro-spinal meningitis, 
637. See Meningitis, Epi- 
demic, Labyrinthine In- 
flammation IN, 637. 
influenza, involvement of internal 
ear in, 637. 
Epidural abscess, 583. 
perforation for evacuation of, 583. 
technique of operation, 583. 

after-treatment. 584. 
thrombus in lateral sinus when in 
floor of abscess, 585. 
Epithelioma of the auricle, 213. 
Epitympanic recess, the, 13. 

space, the. 13. 
Erysipelas of auricle. 201. 
Eustachian canal, the, 13. 
catarrh, 304. See Eustachian 

Tube. Congestion of, 304. 
catheter, 107. 
curve of, 108. 
faucial, 125. 
Noyes'. 124. 
tube, the. 19. 

catheterization of, 107. 
congestion of, 304. 
setiology of, 304. 
diagnosis of, 306. 

functional examination, 308. 
physical examination, 306. 
pathology of, 304. 
prognosis of, 310. 
symptomatology of, 305. . 
treatment of, 311. 
astringents, 312, 314. 
bougie. 313. 
inflation. 311. 
naso-pharynx, 314. 
prophylaxis, 316. 
use of vapors, 315. 
dilatation of, by electric bougie, 

377- 
effect of stenosis of, on upper 

tone limit, 64. 
function of muscles of. 56. 
mucous membrane of, 23. 



Eustachian tube, muscles of, 28. 
tympanic opening of, 13, 99. 
veins of, 30. 
Ewald, 61. 

Examination of ear, functional, 142. 
physical, 73. 

obstacles to, 95. 
value of auscultation in, 103. 
value of probe in, 100. 
of mouth, 132. 
of nose and pharynx, 132. 
Excision of portion of malleus, 498. 
Exostoses of external auditory me- 
atus, 285. See Meatus, Ex- 
ternal Auditory, Exostoses 
of, 285. 
Exploration of cerebellum, 592, 593. 

of cerebrum, 586. 
Exploratory myringotomy, 489. 
External auditory meatus, absence 
of, 176. 
congenital occlusion of, 176. 

treatment of, 181. 
diseases of, 217. 
examination of, 88. 
function of, 50. 
fundamental note of, 51. 
malignant tumors of, 213. 
ear, the, 4. 

ligament of the malleus, 18. 
otitis, acute circumscribed, 217. 
See Otitis, Acute Circum- 
scribed External, 217. 
otitis, hemorrhagic, 265. 
Extradural abscess, 471. 
location of, 471. 
prognosis of, 472. 
statistics of, 472. 
symptomatology of, 471. 
treatment of. 472. 

Facial artery, the, 30. 
nerve, the, 12. 

injury of, in intratympanic oper- 
ations, 524. 
injury of, in mastoid operations. 
540. 
paralysis of, as a symptom of sec- 
ondary labyrinthine involve- 
ment. 630. 
Fallopian canal, the, 12, 32. 
Fatigue of auditory nerve, 70. 164. 
Fan. ear-trumpet in shape of, 

696. 
Fenestra ovalis, the, 12. 
niche of, 12. 



INDEX. 



/03 



Fenestra rotunda, the, 12. 

Fibroma of the auricle, 206. 

Field of middle-ear operations, 

preparation of, 483. 
Fischenisch, 211. 
Fissura intertragica, the, 5. 
Fissure, the Glaserian, 9. 

the Rivinian, 92. 
Fistula congenita auris, 179. 
Flap formation in radical operation 

for chronic otorrhcea, 552. 
Flesch, 202. 

Fluid in tympanum, signs of, 365. 
Folds of the membrana tympani, 91. 
Foreign bodies in the ear, 279. 
Fossa, glenoid, 9. 

of the helix, 5. 

Rosenmiiller's, 138. 

the jugular, 13. 

the middle cranial, 446. 
Fracture of base of skull, rupture of 

membrana tympani in, 292. ■ 
Frank, 120. 
Frey, 543. 
Functional examination, 142. 

instruments for, 148. 

technique of, 155. 

value of, in differential diagnosis, 

151. 

nervous disorders, auditory dis- 
turbances in, 662. 

Fundamental note of sounding body, 
the, 49. 

Furuncle, 217. See Otitis, Acute 
Circumscribed External, 
217. 

Gad, 51, 54, 65. 

Galton whistle, the, 149. 

method of using, 159. 

modification of, 156. 

physics of, 149. 

value of graduations of, 149. 
Galvanic reaction of auditory nerve, 

167. 
Ganglion, Meckel's, 32. 

otic, 31, 32. 
Gangrene of auricle, 205. 
Gelle, 69, 163. 

General nervous diseases, effect of, 
upon perceptive mechanism, 
646. 
Gerlach, 24. 

Glands of the auricle, 23. 
Glaserian fissure, the, 9. 
Glenoid fossa, the, 9. 



Glosso-pharyngeal nerve, the, 31. 

tympanic branch of, 31. 
Gout, aural complications in, 659. 
Gradenigo, 14, 146, 160, 164, 165, 

658. 
Granulation tissue, removal of, 416. 
Green, 194, 493. 
Gruber, 121, 230, 265, 491, 493. 
Gruening, 201, 462. 
Grunert, 421. 

Haberman, 206. 
Haematoma auris, 202. 

of auricle, 184. 
Haemorrhage, labyrinthine, 608. See 

Labyrinthine Hemorrhage, 

608. 
Haemorrhagic external otitis, 265. 
Hair cells, the, 39, 42. 
Hamular process, the, 36. 
Harmonics, 49. 

Hartmann, 108, 157, 211, 260, 493. 
Hartmann's series of tuning forks, 

158. 
tenotome, 495. 
Hasslauer, 300. 
Haug, 207. 

Head mirror, the, 80, 81. 
Hearing, artificial aids to, 695. 
Hearing-horn, London, 695. 
Hearing, qualitative tests of, 148, 

155- 

quantitative tests of, 142, 145, 155. 

value of whisper in, 144. 
Llelicotrema, 36. 
Helix, the, 4. 

anomalies of, 174. 

spine of, 5. 
Helmholtz, 18, 52. 
Hensel, canal of, 2>7- 
Herpes of auricle, 193. 

treatment, 194. 
History, scheme of, 139. 
Hommel, 390. 
Horizontal semicircular canal, the. 

12. 
" Hutchinson teeth," 614. 
Hyperaemia of labyrinth, 604. See 
Labyrinth, Hyper.emia of. 
604. 
Hyperaesthesia acustica. 71. 
Hypertrophic rhinitis. 680. 

signs of. 135. 
Hypertrophy of third tonsil. 689. 

treatment of, 691. 
Hyrtl, 492. 



;°4 



INDEX. 



Hysteria, disturbance of audition in, 

665. 
diagnosis of. 666. 
prognosis of, 667. 
symptomatology of. 665. 
treatment of. 667. 

Ice-coil, in treatment of acute puru- . 
lent otitis media, 351. 
in treatment of mastoiditis. 460. 

statistics of. 461. 
in treatment of otitis media puru- 
lenta residua. 432. 
Illumination, method of. 76. 
Incision of membrana tympani, 324, 
337* 350. 375- 486. 488. 
in mastoditis, 461. 
of posterior fold. 492. 
Incisures of Santorini, the. 7. 
Incudo-stapedial articulation, posi- 
tion of. 97. 
joint, disarticulation of. 498. 504. 
ligament, the. 19. 
Incus, the, 17. 

division of long process of. 498. 
frequency of caries of. in middle- | 

ear suppuration. 523. 
ligaments of, 18. 

plastic operation for purpose of 
uniting to membrana tympani 
directly. 500. 
removal of. 505. 506. 
Infection, bacteriological, in intra- 
tympanic inflammation, 300. 
301. 
Infectious diseases, acute, aural com- 
plications in. 651. 
diseases. influence of severity 
of. upon aural complications. 
652. 
Inflammation, intratympanic. 300. 
bacteriological infection in, 300. 301. 
of labyrinth, secondary. 617. See 
Labyrinth. Secondary In- 
flammation of. 617. 
of the mastoid process. 449. 
Inflammatory affections of the auri- 
cle, 200. 
Inflation, methods of. 103. 
Influenza, epidemic, effect of, on per- 
ceptive apparatus, 637. 
Iniundibulum. the, 36. 
Injuries of the membrana tympani. 

291. 
Injury of facial nerve in mastoid op- 
eration, 540. 



Inner tympanic wall. the. 12. 

plane of. 13. 
Instruments for functional examina- 
tion. 148. 
preparation of. for operations, 
138. 
Interference otoscope. 165. 
Internal carotid artery, the. 13. 30. 
Internal ear. the. 34. 
involvement of, in acute infectious 
diseases, 634. See Perceptive 
Mechanism, Involvement of, 
in Acute Infectious Dis- 
eases, 634. 
involvement of, in diphtheria. 637. 
involvement of. in epidemic influ- 
enza, 637. 
involvement of. in parotiditis. 636. 
involvement of, in typhoid and 

typhus fever. 636. 
syphilis of. 613. See Labyrinth, 
Specific Inflammation of, 

613. 
Internal jugular vein. the. 13. 

maxillary artery. 29. 
Interossicular ligaments, the. 19. 
Intertrigo of auricle. 187. 
Intracranial complications of mid- 
dle-ear suppuration, treatment 
of. 569- 
of tympanic inflammation. 463. 
Intratympanic adhesions, signs of, 

95- 
folds. 25. 
ligaments, the. 17. 

anomalies in tension of. 367. 
muscles, the, 2j. 

pressure, influence of. on labvrinth, 
62. 
Introduction of Eustachian catheter,, 
technique of, ill. 

Jacobs. 557. 
Jankau. 166. 167. 
Jansen, 554. 557. 
Jugular fossa, the. 13. 
Junken. 209. 

Kaiser. 39. 

Katz. 43. 

Kessel. 125. 501. 510. 

Kipp, 207, 209. 

Knapp. 400. 472. 

Koch. 476, 478. 

Koenig's rods. 150. 

Korner, 445, 476. 4/8. 553- 



INDEX. 



705 



Kosegarten, 395. 
Kramer, 69, 121. 
Kretschmann, 522, 
Kiister, 546. 



557- 



Labyrinth, acute inflammation of, 
secondary to acute purulent 
otitis media, 629. 
aetiology of, 629. 
diagnosis of, 631. 

functional examination, 631. 
physical examination, 631. 
pathology of, 629. 
prognosis of, 632. 
symptomatology of, 630. 
facial paralysis in, 630. 
treatment of, 632. 
anaemia of, 601. 
aetiology of, 601. 
diagnosis of, 602. 

functional examination, 602. 
physical examination, 602. 
prognosis of, 602. 
symptomatology of, 601. 
treatment of, 602. 
anatomy of, 34, 37. 
blood supply of, 44. 
concussion of, 72. 
effect of increased tension of, on 

sound perception, 63. 
effect of middle-ear changes upon, 

61. 
hyperaemia of, 604. 
aetiology of, 604. 
diagnosis of, 605. 

functional examination, 605. 
physical examination, 605. 
pathology of, 605. 
prognosis of, 606. 
symptomatology of, 605. 

vertigo in, 605. 
treatment of, 606. 
physiology of, 57. 
secondary inflammation of, follow- 
ing chronic middle-ear inflam- 
mation, 617. 
diagnosis of, 622. 

functional examination of, 623. 
galvanic reaction of auditory 

nerve, 624. 
physical examination, 622. 
pathology of, 617. 
prognosis of, 624. 
symptomatology of, 618. 

influence of condition of upper 
air passages, 620. 



Labyrinth, secondary inflammation 
of, sympathetic involvement of 
opposite ear, 621. 
treatment of, 625. 
middle ear, 625. 
torpidity of nerve, 626. 
treatment of upper air passages 
in, 627. 
specific inflammation of, 613. 
aetiology of, 613. 
diagnosis of, 614. 

functional examination, 614. 
physical examination, 614. 
pathology of, 613. 
prognosis of, 614. 
symptomatology of, 613. 
treatment of, 615. 
syphilis of, 613. 
the bony, 34. 
the membranous, 37. 
Labyrinthine capsule, rarefying oste- 
itis of, in otosclerosis, 382. 
Labyrinthine embolism and throm- 
bosis, 611. 
aetiology of, 611. 
pathology of, 611. 
prognosis of, 612. 
symptomatology of, 611. 
treatment of, 612. 
haemorrhage, 608. 
aetiology, 608. 
diagnosis of, 609. 
pathology of, 608. 
prognosis of, 610. 
symptomatology of, 609. 
treatment of, 610. 
tension, variations in, 62. 
Lagena, the, 38. 
Lamina spiralis, 35. 
membranacea, 36. 
ossea, 36. 
Lateral sinus, 445. 
anomalies in position of. 445. 
thrombosis of, 466. See Sinus 
Thrombosis, 466. 
treatment of, 571. 
wounds of, 536, 538. 
Leiter's coil, 229. 

in acute purulent otitis media, 351. 
Lenticular process, the. 17. 
Letters, logographic value of. 144. 
Leucaemia, aural involvement in. 657. 
Levator-palati muscle, the, 28. 
Ligament, anterior, of the malleus. 
18. 
external, of the malleus. 18. 



;o6 



INDEX. 



Ligament, incudo-stapedial, 19. 

malleo-incudal. 19. 

of the incus, the posterior. 18. 

posterior, of the malleus, : ; 

stapedio-vestibular. 19. 

superior, of the malleus. iS. 
Ligaments of the incus. iS. 

of the malleus. 17. 

of the stapes. 19. 

the interossicular. 19. 

the intratympanic. 17. 
Light reflex, the. 91. 

sources oi 76. 
Lipoma of the auricle. 207. 
Lobule, the. 6. 

anomalies of. 174. 

thickening of. 204. 

tumors oi. 208. 
Loewenberg. 119. 218. 
Logographic value of consonants. 

144- 

London hearing-horn. 695. 

Lorgnette, ear-trumpet. 696. 

Lucae. no. 147. 153. 165. 391. 392. 502 
ssure sound of. 391. 

Lucae's method of applying pro- 
motion to ossicular chain. 391. 
392. 

Ludevs-ig. 421. 422. 523. 525. 

Lupus of the auricle. 197. 198. 

Lustre of membrani tympani. 92. 

Lymphatics of the ear. 31. 

McBride, 175. 

Macewen. 466. 475. 47S. 
Macula acustica. 39. 

cribrosa. 44. 
Malformation of the auricle. 176. 
Malformations of the ear, treatment 

of. 177. 
Malignant tumors of the auricle. 

213. 
Malleo-incudal articulation, function 
of. 53. 

ligament, the. 19. 
Malleus, the. 14. 

anterior ligament of. 18. 

division of anterior ligament. 495. 

excision of portion of. 49S. 
:::ernal ligament of. 18. 

ligaments of the. 17. 

posterior ligament of. 18. 

superior ligament of. 18. 
Malposition of auricle. 176. 
Manubrium mallei, position of. 00. 
Marian, 208. 



I Mastoid, antrum. 442. 443. 
position of. 443. 448. 
relation of. to intracranial struc- 
tures, 4-14; 
condition in infancy. 447. 
determination of tenderness over. 

455- 

diploic. 443. 

inflammation of (mastoiditis). 449. 
aetiology of. 449. 

influence of diathetic condi- 
tions, 459. 
diagnosis of. 455. 

tenderness on pressure. 455. 

-^ing of canal wall. 455. 
variations in temperature. 452. 
pathology of. 450. 

::;:ection of lateral sinus. 451. 
infection through squamous 
plate. 451. 
perforation into digastric fossa. 

450. 457 
perforation into posterior cranial 
fossa. 450. 
perforation through cortex. 

450. 
perforation through roof of 
tympanum. 450. 
prognosis of. _ : - 
symptomatology of. 452. 

intracranial involvement. 453. 
tre itment of. 459. 
abortive measures. 459. 460. 
importance of free drainage 

through meatus. 459. 
local application of cold. 460. 
operation. 461. 462. 
statistics of abortive treatment, 
461. 
internal surface of. 445. 
local necrosis of. 450. 
operation. 532. 

accidents in. 336. 538. 
after-treatment. 537 
dressing after. 536. 
facial nerve, injur}- to. 540. 
Frey's method of paraffin injec- 
tion. 543. 
instrument for. 534. 
Mosetig-Moorhof's. 542. 
paraffin injection. : _ 
permanent opening behind the 

ear. 541. 
removal of softened bone. 535. 
technique of. 553. 
Trautmann's. 541. 



INDEX. 



707 



Mastoid operation, variations of tech- 
nique according to the age of 
patient. 538. 
pneumatic, 442. 
portion of temporal bone, 11. 
process, anatomy of, 442. 
internal surface,. 445. 
oedema over, from circumscribed 

external otitis, 224. 
sclerotic, 442, 443, 450. 
squamous suture, the, 9, 11. 
topography of, 444. 
Maxillary artery, the internal, 29. 
Meatus, bony, 9, 11. 
development of, 7. 
cartilaginous, 6. 
external auditory, epithelioma of, 

213- 
exostoses of, 285. 
aetiology of, 285. 
diagnosis of, 286. 
pathology of, 285. 
prognosis of, 287. 
symptomatology of, 286. 
treatment of, 288. 
foreign bodies in, 279. 
diagnosis of, 281. 
pathology of, 279. 
prognosis of, 281. 
removal of, by posterior inci- 
sion, 283. 
symptomatology of, 280. 
treatment of, 282. 
sarcoma of, 216. 
Mechanism, the perceptive, 33. 
diagnosis of diseases of, 155. 
Meckel's ganglion, 32. 
Membrana basilaris, the, yj- 
epithelium of, 41. 
function of, 59. 
flaccida, the, 23. 
limitans, the, 40. 
reticularis, the, 43. 
tectoria, the, 43. 
tympani, the, 821. 

characteristics of, 92. 

color of, 92. 

determination of presence of, 89. 

folds of, 91. 

function of, 51. 

incision of, 325, 486, 488. 

lustre of, 92. 

multiple incision of, 491. 

physical examination of, J2>- 

landmarks in, 90. 
pockets of, 24. 



Membrani tympani, position of, 93. 
in infancy, 94. 
quadrants of, 97. 
relaxation of, 366. 
reproduction of, after removal, 

513- 

rupture of, 292. 

by inflation, 130. 
segments of, 91. 
signs of retraction of, 91. 
structure of, 93. 
use of artificial drum membrane, 

440. 
wounds and injuries of, 291. 
aetiology of, 291. 
diagnosis of, 293. 
pathology of, 291. 
prognosis of, 294. 
symptomatology of, 292. 
treatment of, 294. 
Membrane, basilar, epithelium of, 
41. 
of Corti, 43. 
of Reissner, Z7- 
Shrapnell's, 92. 
Membranous cochlea, the, 40. 

labyrinth, the, 2>7- 
Meningitis, acute, involvement of 
perceptive mechanism in, 641. 
diagnosis of, 643. 

functional examination, 643. 
pathology of, 641. 
prognosis of, 644. 
symptomatology of, 641. 
treatment of, 644. 
epidemic cerebro-spinal, labyrin- 
thine inflammation in, 637. 
diagnosis of, 639. 

functional examination, 639. 
physical examination, 639. 
pathology of, 637. 
prognosis of, 639. 
symptomatology of, 638. 
treatment of, 640. 
Meningitis, otitic, 463. 
diagnosis of, 465. 

choked disk, 465. 
operative procedures for relief of. 
579- 
evacuation of ventricular fluid, 

580, 581. 
exposure and incision of dura. 

580. 
lumbar puncture, 581. 

as a means of diagnosis. 582. 
as a therapeutic measure. 5S3. 



;o8 



INDEX. 



Meningitis, pressure of spinal fluid 
increased in, 583. 
prognosis of, 466. 
serous meningitis, 463, 464, 465. 
symptomatology of, 464. 

choked disk, 466. 
treatment of, 466. 

internal medication, 466. 
surgical measures, 466. 
purulent, 583. 
Metastatic aural involvement, 655. 
Methods of catheterization, 119-121. 
Meyer, 692. 
Microtia, 176. 

treatment of, 177. 
Middle cranial fossa, 446. 

accidental opening of, 538. 
Middle ear, acute catarrhal inflam- 
mation of, 327. See Otitis 
Media, Acute Catarrhal, 
327. 
acute purulent inflammation of, 
341. See Otitis Media, Acute 
Purulent, 341. 
chronic catarrhal inflammation 
of, 357- See Otitis Media, 
Chronic Catarrhal, 357. 
chronic purulent inflammation 
of, 397. See Otitis Media, 
Chronic Purulent, 397. 
diseases of, 297. 
bacteriological infection in, 300, 

301. 
classification of, 297. 
inflammation of, intracranial com- 
plications of, 463. 
surgery of, 481. 
Middle-ear operations. 481. 

adhesions, division of, 496, 497. 
anaesthesia in, 484. 
classification of, 485. 

involving the intratympanic soft 

parts, 485. 
involving the membrana tym- 

pani alone, 485. 
involving the ossicular chain, 486. 
instruments, 481. 
position of patient, 485. 
preparation of field of operation, 

483. 
statistics of author's cases, 512, 527, 

529, 530. 
suppuration, in division of adhe- 
sions in, 496. 
intracranial complications, treat- 
ment of, 564. 



Middle-ear suppuration, radical oper- 
ation for, 525. 
sinus thrombosis in, 571. 
vertigo, 382. 
Miot, 500. 
Mirror, 78, 81. 

Mobility of membrana tympani and 
ossicles, determination of, 100. 
Mobilization of stapes, 498. 
Modiolus, the, 35. 
central canal of, 36. 
spinal canal of, 36. 
Mouth, examination of, 132. 
Mosetig-Moorhof, 542. 
Mosetig-Moorhof's operation for 
closure of opening behind the 
ear, 542. 
Mucous membrane of the Eustachian 
tube, 23. 
of the tympanum, 23. 
of the tympanum, reduplications of, 
_ 23-26. 
Multiple incision of membrana tym- 
pani, 491. 
Mumps, aural complications in, 636. 
Muscle, the levator palati. 28. 
the petro-salpingo-staphylinus, 28. 
the salpingo-pharyngeus. 28. 
the spheno - salpingo - staphylinus, 

28. 
the stapedius, 28. 
the tensor palati, 28. 
the tensor tympani. 13. 27. 
Muscles of the ear, 26. 

of the Eustachian tube, 28. 
the intratympanic, 2^]. 
function of. 55. 
Muscular sense, the, 61. 
Musical notes, perception of. 60. 
Myringotomy, 486. 
exploratory, 489. 
partial, 490. 

Nasal cavity, method of examining, 

135. 

septum, deformities of, 684. 
Naso-pharyngeal catarrh, 693. 
Naso-pharyngitis. chronic. 693. 
Naso-pharynx, diseases of, 678. 

examination of, 132. 
Necrosis of auricle from eczema, 

189. 
Nephritis, aural affections in, 654. 
Nerve, the auditory, 45, 47. 
fatigue of, 164. 
galvanic reaction of, 167. 



INDEX. 



709 



Nerve, the auditory, loss of function 
of. from disuse, 181. 
overstimulation of, 70. 
torpidity of, 626. 

deafness. 597. 

the chorda tympani, 32. 

the cochlear, 45. 

the vestibular. 46. 

the Vidian. 2> 2 - 
Nerves of the ear, 31. 

auricularis magnus, the, 31. 

auriculo-temporal, the, 31. 

cervical plexus, the, 31. 

cochlear. 45. 

facial, 31. 

glosso-pharyngeal, the, 31. 

occipitalis minor, the, 31. 

otic ganglion, the, 31. 

petrosal, the, 32. 

pneumogastric, the, 31. 

trigeminus, the, 31. 

vestibular, 46. 

Vidian, t> 2 - 
Neurasthenia, impairment of audi- 
tion in, 662. 

diagnosis of, 663. 

prognosis of, 665. 

treatment of, 665. 
Niche of fenestra rotunda, 12. 

the Rivinian, 22. 
Nitrous oxide, use of, 234, 260, 326, 

336, 349- 
Nose and naso-pharynx, method of 
examining, 132, 135. 

diseases of, 678. 
Noyes' Eustachian catheter, 124. 
Nuel's space, 42. 

Obstacles to catheterization, 122. 

to otoscopy, 95. 
Occipital artery, the, 29. 
Okada, 400. 
Oliver, 68. 

Operation for excision of ossicles 
and curettement of the tym- 
panum, 421. 
author's statistics of, 421. 
Grunert's statistics of, 421. 
Ludewig's statistics of, 421. 
mastoid, 532. See Mastoid Oper- 
ation, 532. 
Stacke's, 525. 
Stacke-Schwartze's, 547. 
middle-ear, 481. 

classification of, 485. See Mid- 
dle-ear Operations, 485. 



Operation, Mosetig-Moorhof's, 542. 
plastic, for uniting incus or stapes 
to the membrana tympani di- 
rectly, 500. 
radical, for chronic otorrhcea, 546. 
Trautmann's, 541. 
upon ossicles, 498. 
Opiates, use of, in otalgia, 336. 
Os orbiculare, 17. 
Osseous meatus, the, 7. 

development of, 7. 
Ossicles, the, 14. 
development of, 14. 
leverlike action of, 53. 
operations upon, 498. 
removal of, 501. 
technique of, 502. 
in middle-ear suppuration, 516. 
Ossicular chain, function of, 52. 
Ossiculectomy, 501. 
after-treatment, 511, 529. 
author's statistics of after-results, 

512. 
author's statistics in non-purulent 
otitis, 529, 530. 
in purulent otitis, 527, 530. 
carious incus, 523. 

author's statistics of, results in, 
523- 
Schroeder's statistics, 527. 
technique of, in non-suppurative 
cases, 502. 
in suppurative cases, 516. 
value of, 521, 531. 
Ossification of the auricle, 204. 
Osteitis, rarefying, of the labyrin- 
thine capsule in otosclerosis, 
382. 
Ostmann, 24, 58. 
Othematoma of auricle, 202. 

treatment of, 203. 

Otic ganglion, 31, 2> 2 - 

Otitic meningitis, 463. 

diagnosis of, 465. 

choked disk, 465. 
prognosis of, 466. 
serous meningitis, 463, 464, 465. 
symptomatology of, 464. 

choked disk, 464. 
treatment of. 466. 

internal medication. 466. 
surgical treatment of, 466. 579. 
Otitis, acute circumscribed external, 
217. 
aetiology of, 217, 
diagnosis of. 221. 



IO 



INDEX. 



Otitis., acute circumscribed external, 

diagnosis of. 221. 
enlargement of cervical glands 

in. 220. 
pathology of, 218. 
prognosis of. 225. 
symptomatology of, 219. 
treatment of, 226. 
acute diffuse external, 255. 
aetiology of. 255. 
diagnosis of, 256. 
pathology of. 255. 
prognosis of, 258. 
symptomatology of, 256. 
treatment of, 258. 
chronic circumscribed external, 236. 
chronic diffuse external, 238. 
aetiology of, 238. 
diagnosis of, 244. 
pathology of, 239. 
prognosis of, 249. 
symptomatology of, 242. 
treatment of. 250. 
chronic parasitic external. 239. 
externa circumscripta acuta. 217. 

See Otitis, Acute Circum- 
scribed External. 217. 
circumscripta symptomatica, 223. 
diffusa chronica, 238. See 

Otitis, Chronic Diffuse 

External, 238. 
external, croupous and diphtherit- 
ic, 261. 
treatment of. 263. 
external hemorrhagic, 265. 

treatment of, 266. 
media, acute catarrhal, 327. 
aetiology of. 327. 
diagnosis of, 332. 

functional examination, 334. 

physical examination, 332. 
elevation of temperature in, 330. 
pathology of, 328. 

bacteria in aural discharges 
328. 
prognosis of, 334. 

influenced by bacteriological 
investigation, 335. 
symptomatology of, 329. 

in adults. 329. 

in children, 330. 
treatment of. 336. 

necessity for incision, 337. 

relief of pain, 336. 

removal of discharge, 337. 

use of opiates, 336. 



Otitis media, acute purulent. 341. 
aetiology of. 341. 
diagnosis of. 346. 

functional examination. 347. 

physical examination. 346. 
pathology of, 342. 

bacteriological infection. 342. 
prognosis of, 348. 
symptomatology of. 344. 

involvement of intracranial 
structures, 345. 
treatment of, 349. 

abortive treatment. 350. 351. 

bloodletting. 352. 

exuberant granulation tissue. 

354- 

ice-coil in treatment. 351. 

incision. 349. 

indication for use of powders, 
356. 

prevention of mastoid involve- 
ment, 351. 

secondary myringotomy, 354. 

technique of incision in. 349. 
chronic catarrhal. 357. 
chronic catarrhal. hyperplastic, 

379- 
aetiology of, 379. 

influence of sex, 380. 

simultaneous involvement of 
both ears, 380. 
diagnosis of, 384. 
functional examination. 386. 

difference in audition for voice 
and for sharp sounds, 386. 

differential diagnosis from oto- 
sclerosis, 387. 

estimation of degree of laby- 
rinthine involvement, 387. 
physical examination. 384. 

appearance of membrana flac- 
cida, 385. 

atrophy of membrana tym- 
pani, 384. 

calcific deposits in drum mem- 
brane. 385. 

intratympanic adhesions. 385. 
rotation of ossicles. 377. 
pathology of. 380. 

changes about tympanic fenes- 
tras, 380. 

changes in tympanic vault, 
381. 

displacement of ossicular 
chain. 381. 

involvement of labyrinth, 381. 



INDEX. 



711 



Otitis media, chronic catarrhal, hy- 
perplastic, pathology of, oto- 
sclerosis, rarefying osteitis of 

the labyrinthine capsule, 382. 
prognosis of, 388. 
symptomatology of, 382. 

auditory fatigue, 383. 

disappearance of tinnitus in 
late stages, 384. 

effect on mental conditions, 383. 

pain, 382. 

tinnitus, 382. 

vertigo, 382. 
treatment of, 389. 

internal medication, 394. 

pilocarpine, 394. 

potassium iodide in beginning 
otosclerosis, 395. 

surgical measures, 392. 

division of adhesions, 392. 

exploratory myringotomy, 392. 
value of inflation, 389. 
value of passive motion and mas- 
sage, 389. 

Hommel's method, 390. 

pneumo-massage, 390. 

pressure sound, 391. 
media, chronic catarrhal, hyper- 
trophic, 358. 
aetiology of, 358. 

heredity, 359. 
diagnosis of, 364. 

functional examination, 368. 

physical examination, 364. 
pathology of, 360. 

change to hyperplastic form, 
361. 

effect on labyrinth, 361. 

structural changes produced, 
360. 
prognosis of, 369. 

influence of the nose and the 
naso-pharynx upon, 369. 
symptomatology of, 362. 

impairment of audition, 362. 

pharyngeal pain, 363. 

tinnitus, 362. 

vertigo, 363. 
treatment of, 370. 

electrolytic method, 372. 

Eustachian tube, 371. 

incision of membrana tympani, 
37 S- 

injection of fluids, 374, 377. 

injection of medicated vapors, 
377- 



Otitis media, chronic catarrhal, hy- 
pertrophic, treatment of, me- 
chanical support of ossicles, 
378. 

passive motion, 378. 

removal of effusion, 374. 

surgical measures, 378. 

tenotomy of tensor tympani, 
376. 

tympanum, 374. 

upper air passages, 370. 

value of permanent opening in 
membrana tympani, 379. 
media, chronic catarrhal, inflamma- 
tion of labyrinth in, 617. 
chronic purulent, 397. 
aetiology of, 397. 

diathetic conditions, 397. 
diagnosis of, 405. 

functional examination, 410. 

physical examination, 405. 

auscultatory signs, 409. 

determination of presence or 
absence of ossicula, 408. 

examination of upper and pos- 
terior quadrant, 408. 

value of probe in diagnosis, 
407. 

various otoscopic appearances, 
405, 406. 
pathology of, 397. 

caries of ossicles, 398. 

cerebellar abscess in, 400. 

cholesteatoma, 401. 
acute symptoms following,. 
402. 

extension of purulent inflam- 
mation to labyrinth, 400. 

frequent involvement of incus, 
398. 

involvement of membrana tym- 
pani, 398. 

labyrinthine involvement, 399. 

mastoid involvement. 400, 401. 

meningitis in, 400. 

result of previous catarrhal in- 
flammation, 397. 
prognosis of, 410. 

factors determining probable 
relief of otorrhcea. 411. 

importance of chronic otor- 
rhcea, 411. 

value of physical appearances 
in determining improvement 
in hearing, 411. 
symptomatology of. 402. 



712 



INDEX. 



Otitis media, chronic purulent, symp- 
tomatology of, development 
of aural polypi in, 404. 

evidences of labyrinthine in- 
volvement, 405. 

facial paralysis, 403. 

intermittence of discharge, 403. 

presence of granulation tissue, 
404. 

secondary infection of canal, 

403-. 
treatment of, 412. 

after removal of carious bone. 

422, 423- 
artificial protection of mucous 

membrane of middle ear, 419. 
aural polypi, removal of, 416, 

417. 
cholesteatoma, 424. 
cleansing of tympanic vault, 

418, 419. 
dermoid transformation of 

tympanic mucous membrane, 

422. 
effect of treatment on audition, 

422. 
granulation tissue, 416. 
importance of thorough cleans- 
ing of canal. 412. 
importance of treatment of 

upper air passages, 414. 
mucous membrane of middle 

ear, 413. 
prevention of growth of asper- 

gillus, 417, 418. 
removal of diseased bone, 420. 
statistics of operation. 425. 
use of astringents, 418. 
value of internal medication, 

425. 
value of powders, 414, 415. 
media, chronic non-suppurative, in- 
flammation of labyrinth in, 617. 
See Labyrinth, 617. 
media, chronic suppurative, inflam- 
mation of labyrinth in, 617. 
See Labyrinth, 617. 
media, intracranial complications 

of, 463. 
media purulenta, treatment of men- 
ingitis in, 583. 
media purulenta chronica, as a 
cause of cerebellar abscess, 476. 
cerebral abscess, 472. 
extradural abscess, 471. 
sinus thrombosis, 466. 



Otitis media purulenta residua, 426. 
acute cases, 426. 

aetiology of, 426. 
diagnosis of, 428. 
physical examination, 428. 
pathology of, 426. 

development of granulation 

tissue, 427. 
infection of serous discharge 
in canal. 427. 
prognosis of, 429. 

danger of resulting purulent 
condition, 429. 
symptomatology of. 427. 

facial paralysis, 428. 
treatment of, 430. 

incision in acute cases, 431, 

432. 
irrigation. 430. 

prevention of mastoid involve- 
ment, 431. 
upper air passages, 430. 
use of astringents, 430. 
media purulenta residua, chronic 
cases, 432. 
diagnosis of, 436. 

evidences of secondary labyrin- 
thine involvement, 437. 
functional examination, 436. 
physical examination, 436. 
recognition of slight discharge, 

434- 
pathology of, 433. 
prognosis of, 437. 

spontaneous improvement, 438. 
symptomatology of, 435. 

development of cholesteatoma, 

435- 

facial neuralgia, 436. 

persistent pain over mastoid, 
436. 
treatment of, 438. 

Eustachian tube, 438. 

hypertrophic conditions, 439. 

importance of hygienic meas- 
ures, 438. 

internal medication with pilo- 
carpine, 441. 

mobilization of stapes, 440. 

relief of tension about round 
window, 441. 

relief of tension anomalies, 439. 

stapedectomy, 440. 

value of artificial drum mem- 
brane, 440. 
media sclerotica, 433. 



INDEX. 



713 



Otitis media serosa, 317. See Tubo- 
tympanic Congestion, 317. 
media, subacute, 317. See Tubo- 
tympanic Congestion, 317. 
Otoliths, the 40. 
function of, 60. 
Otomycosis, 242. 

Otosclerosis, potassium iodide in, 395. 
Otoscope, of Siegel, 392. 
the interference, 165. 
the pneumatic, 101. 

demonstration of anomalies in 
tension of intratympanic liga- 
ments. 367. 
Otoscopy, obstacles to, 95. 

technique of, 96. 
Oval window, the, 12. 
Overstimulation of auditory nerve, 

70. 
Overtones, 49. 
Otorrhcea, chronic, 546. 

danger of infection in, 546. 
operative procedures, 546. 
accidents during, 561. 
exposure of dura, 561. 
exposure of lateral sinus, 562. 
injury to facial nerve, 561. 
perichondritis of auricle, 563. 
author's method, 550. 
Ballance's incision, 547. 
Bergmann's method, 546. 
dressing wound, 560. 

avoidance of foul odor, 560. 
Kuster's method, 546. 
lining of cavity with flaps, 552. 
author's modification of Stacke's 

method, 555-557- 
Ballance's modification, 554. 
closure of wound, 556. 
Jansen's modification, 554. 
Koerner's modification, 553. 
Panse's modification, 553. 
permanent opening left behind 

ear, 557. 
Stacke's method, 552. 
Tiersch, 558, 559. 
precautions to be observed, 550, 

551- 
removal of external wall of tym- 
panic vault, 549. 
results following operation, 560- 

561. 
secondary operation, 561. 
Stacke's operation, 547. 
Stacke-Schwartze operation, 547. 
technique of, 547. 

47 



Parotitis, 629. 
Panse, 553. 

Paraffin injection for deformity fol- 
lowing mastoid operation, 543. 
Papilla acustica, 41. 
Papilloma of the auricle, 212. 
Paracusis Willisii, 624, 643. 
Parsesthesia acustica, 71. 
Parasitic external otitis, 289. 
Parotid gland, secondary involve- 
ment of, in external otitis, 220. 
Parotiditis, involvement of internal 
ear in, 636. 
simulating otitis externa, 225. 
Partial myringotomy, 490. 
Passow, 557. 
Pelvis ovalis, the, 12. 
Pemphigus of auricle, 193. 
Perceptive mechanism, diseases of, 
597- 
mechanism, effect of diseases of 
general nervous system upon, 
646. 
mechanism, involvement of, in 
acute infectious diseases, 634. 
diagnosis of, 635. 
pathology of, 634. 
prognosis of, 635. 
treatment of, 635. 
mechanism, involvement of, in 
acute meningitis, 641. 
diagnosis of, 643. 

functional examination, 643. 
pathology of, 641. 
prognosis of, 644. 
symptomatology of, 641. 
treatment of, 644. 
mechanism, signs of involvement 
of, 155; 
Perichondritis of the auricle, 184, 
200, 563. 
treatment of, 185. 
Petro - salpingo - staphylinus muscle, 

the, 28. 
Petro-squamous suture, the, 12. 
Petrosal artery, the superficial, 29. 

nerves, the, 32. 
Petrous portion of temporal bone. 11. 
Pfliiger, 179. 
Pharyngeal sounds, 118. 

tonsil, hypertrophy of, 689. 

treatment of, 691. 
vault, digital examination of. 133. 
Pharynx, examination of. 132. 
Phonograph, as a test of audition, 
145. 



7H 



INDEX. 



Phonometer, the, 147. 
Physical examination of the ear, 73. 
sources of light for, 76. 
technique of, 83. 
Physiology of ear, 48. 
Pilocarpine, use of, in chronic catar- 
rhal otitis media, 394. 
use of, in primary labyrinthine af- 
fections, 606, 610, 612, 615. 
use of, in secondary labyrinthine 
involvement, 626. 
Pinna, the, 4. 
Plexus, the tympanic, 32. 
Plicotomy, 492. 
Pneumatic mastoid, 442. 
speculum, use of, 101. 
Pneumogastric nerve, auricular 

branch of, 31. 
Pockets of the membrana tympani, 24. 
Politzer, 6, 24, 29, 54, 63, 67, 104, 143, 
265, 346, 362, 391, 395, 444, 445, 
491, 495, 563, 617, 677. 
Politzer's acoumeter, 143. 

bag, 104, 105. 
Politzer's method for maintaining neg- 
ative pressure in meatus, 391. 
Politzerization, method of perform- 
ing, 104. 
value of, as a diagnostic measure, 

131- 
as compared with catheterization, 
130. 
Polyotia, 180. 
Polypi, aural, 404. 
removal of, 416, 417. 
treatment of, 354, 355. 
Pomeroy, 125, 154, 365, 493. 
Pomeroy's faucial catheter, 125. 
Position of the membrana tympani, 93. 

in infancy, 94. 
Posterior, auricular artery, 29. 
fold, the, 22. 
incision of, 492. 
supernumerary, 365. 
ligament of the incus, 18. 

of the malleus, 18. 
wall of the tympanum, 13. 
Powders, use of, in otorrhoea, 356, 

414. 
Preparation of field in middle-ear op- 
erations, 483. 
Presing, 300. 
Pressure of spinal fluid, 582. 

increased in meningitis, 583. 
" Prize-fighter's ear," 184. 
Probe, value of, in examination, 100. 



Process, the auditory, 8. 
the caudate, 5. 
the hamular, 36. 
Processus cochleariformis, the, 13. 
folianus, the, 16. 
gracilis, the, 16. 
triangularis, the, 6. 
Promontory, the, 12, 98. 
Prussak, fibres of, 23. 

space of, 23. 
Pterygo-palatine artery, the, 30. 
Purulent inflammation of the middle 
ear, acute, 341. See Otitis 
Media, Acute Purulent, 341. 
Purulent inflammation of the middle 
ear, chronic, 397. See Otitis 
Media, Chronic Purulent, 
397- 
Pyramid, the, 28. 
anterior, the, 27. 

Quadrants of membrana tympani, 97. 
Qualitative tests for hearing, 148. 
Quantitative tests for hearing, 142. 
Quincke, 463, 581. 
Quincke's lumbar puncture, 581. 

Radical operation for chronic otor- 

rhcea, 546. 
Randall, 97, 445. 
Rathke, 14. 

Receptive mechanism, the, 33. 
Recessus ellipticus, 35. 

epitympanicus, 13. 

of Cutogno, 38. 

sphericus, 35. 
Reduplication of tympanic mucous 

membrane, 23-26. 
Reflecting mirror, the, 78. 

focal length of, 80. 

size of, 80. 
Reflex aural disturbances, 67, 668. 

diagnosis of, 671. 

prognosis of, 671. 

treatment of, 671. 
Reinhardt, 557. 
Reissner, membrane of, 37. 
Relation of mastoid to intracranial 

structures, 444. 
Removal of incus, 506, 507. 

of malleus, 505. 

of ossicles, 501. 
technique of, 502. 

in middle-ear suppuration, 516.. 

of portion of tympanic ring, 505. 

of stapes, 508. 



INDEX. 



715 



Reproduction of membrana tympani 

after removal, 513. 
Reticular membrane, 43. 
Retraction of membrana tympani, 

evidences of, 94. 
Retrahens aurem, 27. 
Rheumatism, aural complications in, 

659. 
Rhinitis, atrophic, 686. 
signs of, 136, 686. 
treatment of, 687. 
hypertrophic, 680. 
signs of. 135, 681. 
treatment of, 683. 
Rhinoscopy, posterior, method of, 

137. 
Richards, 86. 
Ring, the tympanic, 8. 
Rinne, 152. 
Rinne's test, 152. 
variations in, with tuning forks of 
various pitch, 153. 
Rivinian fissure, the, 92. 
notch, the. 92. 
segment, the, 22, 92. 
Rods of Corti, 41. 
function of, 59. 
of Konig, 150. 
Rohrer, 163. 

Rosenmuller, fossa of, 138. 
Round window, the, 12. 
position of, 98. 
relief of tension at, 441. 
Riidinger, 38. 

Rupture of the membrana tympani, 
292. 

Saccule, the, 35, 38. 
Salpingitis, acute, 304. See Eu- 
stachian Tube, Congestion 
of, 304. 
•Salpingo-pharyngeus muscle, the, 28. 
Santorini, incisures of, 7. 
Sappey, 24. 

Sarcoma of the auricle, 216. 
Satyr ear, the, 174. 
Scala media, the, 37, 40. 

tympani. 36. 

vestibuli, ^6. 
Scaphoid fossa, the, 5. 
Scarificator, Bacon's, 227. 

the author's, 228. 
Schimmelbusch, 218. 
Schmiegelow, 524. 
Schroeder, $2j. 
Schubert, 174. 



Schwabach, 154. 
Schwartze, 364, 462, 493, 501. 
Schwartze-Stacke operation, 546, 547. 
Sclerotic mastoid, 443. 
Secondary aural affections, 68. 

inflammation of labyrinth, 617. 
Segment, the Rivinian, 22, 92. 
Sella incudis, 17. 

Semicircular canal, horizontal, 12. 
canals, 35. 

function of, 60. 
Serous meningitis, 463. 
Sextar, 515. 
Short process of malleus, position of, 

90. 
Shrapnell's membrane, appearance 

of, 92. 
Siebenmann, 44, 63, 64, 144, 161, 251. 
Siegel's otoscope, 389, 391, 392. 
Signs of lesion of conducting mech- 
anism, 154. 
of perceptive mechanism, 155. 
Sinus, lateral, 445. 

anomalies in position of, 445. 
Sinus thrombosis, 466, 471. 
diagnosis of, 468, 575. 
choked disk, 469. 
exploration of sinus, 571, 572. 

necessity for asepsis, 571. 
exploratory puncture, 572. 
exploratory incision, 573. 
extension of thrombus into in- 
ternal jugular vein, 574. 
general condition of patient, 469. 
importance of frequent tempera- 
ture observations, 469. 
involvement of cervical lymphat- 
ics, 469. 
prognosis of, 470. 
statistics of, 470. 
symptomatology of, 467. 
constitutional symptoms, 467, 

468. 
rigors, 468. 
treatment of, 470, 576. 
operative, 576. 

after-treatment, 578. 
Sinus tympanicus, the, 12. 
Sound, definition of, 48. 
intensity of, 48. 
pitch of, 48. 
Sounds, auscultatory, 113. 
pharyngeal. 118. 
tubal, 116. 
tympanic. 114, 116. 
Special sense, a sixth, 61. 



7i6 



INDEX. 



Specific inflammation of labyrinth, 
613. See Labyrinth, Spe- 
cific Inflammation of, 613. 
Specula, aural, 83. 
Speculum, pneumatic, use of, 101. 
Spheno-salpingo-staphylinus muscle, 

28. 
Spina tympanica anterior, 8. 
major, 8. 
minor, 8. 
posterior, 8. 
Spinal fluid, normal pressure of, 582. 
increased in otitic meningitis, 583. 
Spinum supra-meatum, the, 9 
Stacke, 525, 526, 547, 549, 552. 
Stacke's operation, 525. 

author's modification of, 526. 
Stacke-Schwartze, 546, 547. 
operation, 547. 

author's modification of, 550, 555, 

557- 
Jansen's modification of, 550, 

555- 
Panse's modification of, 553. 
Koerner's modification of, 553. 
Tiersch grafting in operation, 
author's method, 559. 
Stapedectomy, 527. 
when membrana tympani is intact, 

527- 
when membrana tympani is par- 
tially destroyed, 528. 
Stapedio-vestibular ligament, the, 19. 
Stapedius muscle, the, 13, 28. 
division of, 496. 
function of, 55. 
Stapes, the, 17. 

ligaments of, 19. 
mobilization of, 498. 
movement of, 53. 
plastic operation to unite to mem- 
brana tympani directly, 500. 
removal of, 510. 
Steinbruegge, 160. 
Stetter, 174. 

Strychnine, value of, 395. 
Sulcus laminse spiralis, 36. 

tympanicus, 8. 
Superficial petrosal artery, the, 29. 

temporal artery, the, 29. 
Suppuration, aural, surgical treat- 
ment of intracranial complica- 
tions of, 569. 
Suppuration of middle ear, acute, 
341. See Otitis Media, 
Acute Purulent, 341. 



Suppuration of middle ear, chronic, 
397. See Otitis Media, 
Chronic Purulent, 397. 
Suppurative otitis media, cerebellar 
abscess in, 476. 
cerebral abscess in, 472. 
extradural abscess in, 471. 
Surgical treatment of intracranial 
complications of aural suppu- 
ration, 569. 
Suture, the mastoid squamous, 11. 

the petro-squamous, 12. 
Sympathetic action of auditory appa- 
ratus, 160, 170. 
aural disturbances, 66. 
inflammation of labyrinth, 621. 
Syphilis of auricle, 195. 

of labyrinth, 613. See Labyrinth, 
Specific Inflammation of, 
613. 
Szenes, 175. 

Taylor, 196. 

Technique of functional examination, 

151- 

of physical examination, 83. 
Telephone, as artificial aid to hear- 
ing, 696. 
Temperature in cerebral abscess, 474. 

in sinus thrombosis, 468. 
Temporal bone, 7, 8. 
development of, 7 
petro-mastoid portion, 11. 
squamous portion, 9. 
Tenotomy of stapedius muscle, 496. 
of tensor-tympani muscle, 376, 492. 
Tensor-palati muscle, 28. 
tympani muscle, 13, 27. 

function of, 55. 
tenotomy of, 376, 492. 
Tests, Bing's, 162. 
Eitelberg's, 164. 
Gelle's, 163. 
Gradenigo's, 164. 

of hearing, method of conducting, 
147. 
qualitative, 148. 

value of continuous series of 
musical notes in, 150. 
quantitative, 142, 145. 

value of phonograph, 145. 
value of whisper, 144. 
Rinne's, 152. 
Schwabach's, 154. 
Weber's, 151. 
Teutleuben, 24. 



INDEX. 



717 



Thickening of the lobule, 204. 
Tiersch grafting in radical operation 
for chronic otorrhoea, 558, 559. 
Third tonsil, hypertrophy of, 689. 

treatment of, 691. 
Thrombosis, labyrinthine, 611. See 
Labyrinthine Embolism and 
Thrombosis, 611. 
of lateral sinus, 466, 571. See 
Sinus Thrombosis, 466, 571. 
treatment of, 571. 
Tone limits of audition, 48. 
Tonsil, pharyngeal, hypertrophy of, 
689. 
treatment of, 691. 
Tonsils, faucial, 371, 414. 
Topography of mastoid, 444. 

of tympanum, 97. 
Toynbee, 626. 
Tragus, the, 5. 

anomalies of, 175. 
Trautmann's operation for closure of 

opening behind the ear, 541. 
Treatment of congenital occlusion of 
external auditory meatus, 181. 
of intracranial complications of 

middle-ear suppuration, 569. 
of malformations of the ear, 177. 
of upper air passages in secondary 
inflammation of labyrinth, 627. 
Triquet, 121. 

Troeltsch, pocket of, 347. 
Trumpet, ear, 695. 
Tubal catarrh, 304. 
congestion, 304. 
sounds, 116. 
Tube, the Eustachian, 19. 

congestion of, 304. See Eusta- 
chian Tube, Congestion of, 
304- 
muscles of, 28, 55. 
Tuberculosis, aural involvement in, 

656. 
Tuberculum acusticum, 46. 
Tubo-tympanic catarrh, 317. See 

TUBO-TYMPANIC CONGESTION, 
317. 

Tubo-tympanic congestion, 317. 
aetiology of, 317. 
diagnosis of, 319. 

functional examination, 322. 
physical examination, 319. 

evidences of fluid in tympa- 
num, 320, 321. 
pathology of, 317. 
prognosis of, 322. 



Tubo-tympanic congestion, sympto- 
matology of, 318. 
treatment of, 323. 

evacuation of effusion by inci- 
sion, 325. 
evacuation of effusion by infla- 
tion, 324. 
internal remedies, 326. 
removal of adenoid growths, 316. 
removal of faucial tonsils, 316. 
Tubo-tympanitis, 317. See Tubo- 
tympanic Congestion, 317. 
Tumors of the auricle, benign, 206. 

malignant, 213. 
Tuning forks, Hartmann's, 158. 

method of using, 158. 
Tympanic artery, the, 29. 
bruit, the normal, 114. 
cavity, the, 12. 

inflammation of, intracranial 
complications of, 463. 
membrane, 21. 

reproduction of, after removal, 

513- 

muscles, function of, 55. 

opening of Eustachian tube, 13, 

99. 
plexus, 32. 
ring, 8. 

removal of portion of, 509. 
sounds, 114, 116. 
spine, 8. 

the anterior, 8. 
the posterior, 8. 
vault, 13. 

development of, 14. 
formation of, 9. 
Tympanic inflammation, intracranial 

complications of, 463. 
Tympanum, floor of the, 13. 
dehiscences in, 13. 
inflation of, 102. 
topography of, 97. 
Typhoid fever, involvement of inter- 
nal ear in, 636. 
Typhus fever, involvement of inter- 
nal ear in, 636. 

Umbo, the, 91. 

Upper air passages, treatment of, in 
secondary inflammation of 
labyrinth, 627. 
tone limit, effect of middle-ear 

changes upon, 368. 
tone limit, lowering oi. by middle- 
ear conditions, 161. 



7 i8 



INDEX. 



Urbantschitsch, 14, 66, 69, 71, 109, 

145, 159, 169, 179, 218. 
Utricle, the, 35, 38. 

Vagus, auricular branch of, 31. 
Valsalva's method of inflation, 161, 

430. 
Value of strychnine, 395. 

of powders in otorrhcea, 356, 
414. 
Vaporizer, author's, midde-ear. 315. 
Vault of the tympanum, the, 13. 

development of, 14. 
Vegetations, adenoid, 689. 

treatment of, 691. 
Vein, the internal jugular, 13. 
Veins of the ear, anastomosis of, 
30. 
of the Eustachian tube, 30. 
of the labyrinth, 44. 
Vertigo following inflation of tym- 
panum, 130. 
from impacted cerumen, 271. 
in chronic hyperplastic catarrhal 

otitis media, 382. 
in chronic hypertrophic catarrhal 

otitis media, 363. 
in tubo-tympanic congestion, 319. 
labyrinthine. 601. 
middle ear, 382. 



Vidian artery, the, 30. 
nerve, the, 32. 

Wagenhaiiser 174, 194. 

Walb, 381. 

Walking-stick ear trumpet, 696. 

Weber, 154, 158. 

Weber, F. E., 492. 

Weber-Liel, 69. 376, 377, 493. 

Weber's test, 151. 

Weil, 202. 

Wharton Jones, 69. 

Whisper, as test for hearing, 144. 

Whistle, the Galton, 149. 

Whiting's encephaloscope, 589, 590. 

Wilde's incision. 352, 432, 461. 

Window, the oval, 12. 

the round, 12. 
W T olff, 121. 
Wounds of the auricle, 183. 

of the membrana tympani, 291. 
Wreden, 498. 

Vearslcy. 692. 

Zona pectinata, 41. 

perforata, 41. 

tecta, 41. 
Ziicker. 195. 
Zuckerkandl, 26, 30. 



(1) 



THE END. 



OBSTETRICS. 

A TEXT-BOOK FOR THE USE OF STUDENTS AND 
PRACTITIONERS. 

By J. WHITRIDGE WILLIAMS, 

Professor of Obstetrics. Johns Hopkins University; Obstetrician-in-Chief to the Johns 
Hopkins Hospital; Gynecologist to the Union Protestant Infirmary, Baltimore, Md. 

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OPERATIVE SURGERY 



By JOSEPH D. BRYANT, M. D., 

Professor of the Principles and Practice of Surgery, Operative and Clinical Surgery, 

University and Bellevue Hospital Medical College; Visiting Surgeon to 

Bellevue and St. Vincent's Hospitals ; Consulting Surgeon to the 

Hospital for Ruptured and Crippled, Woman's Hospital, 

and Manhattan State Hospital for the Insane, etc. 

THIRD REVISED EDITION. 

In Two 8vo Volumes. 1,302 pages. 1,576 Illustrations* 90 of 
which are in Color. Sold by Subscription. Cloth, Sio.co. 



"The publication of this volume, somewhat delayed apparently, completes one of 
the best works on operative surgery in existence, and we therefore greet it with pleas- 
ure. The title recites the contents of the volume, in which we find much of what 
is most important in surgery. The pictures are graphic and handsomely executed, and 
the plan of giving illustrations of the instruments required in particular operations is 
maintained. The author's literary style is so good that much is added thereby to the 
pleasure of reading the book." — Medical Record. 

"This book is to be commended without reservation as an admirable guide to 
both the skilled surgeon and the practitioner who is occasionally called on to do sur- 
gical work." — Therapeutic Gazette. 

"The two volumes of the work fulfil every practical need of the practising surgeon, 
and are perfect typographically." — Denver Medical Times. 

"It is seldom that one meets with such an eminently satisfactory work as the 
second volume of Bryant's 'Operative Surgery.' One feature of especial importance 
in the work is the illustrations. No present-day work on operative surgery can be 
satisfactory without the aid of good illustrations, and in this respect Bryant's work is 
very complete." — Philadelphia Medical Journal. 

"The high standard of excellence established in the first volume of Dr. Bryant's 
work is fully maintained in this, the second volume, so that this text-book on opera- 
tive surgery presents a complete, exhaustive, and valuable treatise of this important 
branch of medicine. A reading of both volumes will convince any one that Dr. Bryant 
has something to say, and that, better than this, he well knows how to say it. The 
book is eminently practical and concise, and is a real addition to the literature of this 
important and much-treated subject." — Journal of Medicine and Science. 

"The surgeon who remains without these two volumes of Bryant's ' Operative 
Surgery' — especially a beginner in surgery— deprives himself of one of the valuable 
helps that he could desire." — Virginia Medical Semi-Monthly. 

D . APPLETON AND COMPANY, NEW YORK. 



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